US Global AIDS Policy: Emergency Course Correction Required

Asia Russell

December 1, 2009, marks President Obama’s first World AIDS Day in the White House and the first World AIDS Day for the newly elected Congress. The time is right for a frank assessment of his first year in the fight against global AIDS as President. This analysis focuses on the funding and policy decisions the Administration has made since taking office in January 2009, and assesses the human impact of those decisions.

This article is part of a series on global AIDS issues to be published by Rewire throughout December.  It is drawn from a report co-produced by HealthGAP, Africa Action, Treatment Action Group and Global AIDS Alliance.  A full copy of the report including all tables, graphs and references cited can be found here.  To find other articles in this series, search “global AIDS 2009.”

December 1, 2009, marks President Obama’s first World AIDS Day in the White House and the first World AIDS Day for the newly elected Congress. The time is right for a frank assessment of his first year in the fight against global AIDS as President. This analysis focuses on the funding and policy decisions the Administration has made since taking office in January 2009, and assesses the human impact of those decisions.

The AIDS pandemic continues to ravage the developing world, shattering communities, undermining development, and reversing macroeconomic growth.  On November 9 2009, the World Health Organization launched its first ever study on women and health, concluding that HIV is the leading cause of death worldwide for women in their reproductive years.1 33 million people worldwide are living with HIV, and 2.1 million AIDS deaths occurred in 2008 alone.

However, the AIDS response is beginning to show signs of real progress: the most recent AIDS Epidemic Update published by UNAIDS reveals that steadily increasing AIDS funding has resulted in real but fragile gains. For example, in Kenya, AIDS-related deaths have fallen 29% since 2002 and rates of HIV infection are falling in other countries as well, including the Dominican Republic and Tanzania. HIV mortality rates have decreased in sub Saharan Africa by 18% since 2004.2 In some places where community-wide HIV treatment coverage has been achieved, non-HIV related mortality rates overall are also decreasing, with maternal mortality falling, and significantly more children are surviving.

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These seeds of success are in significant part due to U.S. investment by both the Bush Administration and, importantly, by the Congress, which increased investments for PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) when the budget requests of the Bush Administration budget were anemic.

But President Obama’s first budget request to Congress, for fiscal year (FY) 2010, essentially froze spending for global AIDS at FY2009 levels. Initial information about his likely FY2011 budget request for global AIDS indicates the Administration plans to continue to flat-line funding for life saving programs—at the very same time those programs are
beginning to show population-level impact. Without continued funding increases in the near term the positive public health gains beginning to emerge will likely evaporate. The global community could revert to little more than running in place in response to the global AIDS crisis, rather than making real progress in ending the pandemic and achieving a
sustainable global response to the greatest public health challenge of our generation.

This report card gives President Obama a “D+” for his first year as president. This assessment contrasts his one-year record to the promises he made to get elected, and takes into account the areas where some progress has been made, particularly on HIV prevention and support for integration of reproductive health and HIV prevention and treatment. It
also takes into account pre-existing broad bipartisan support established during the Bush Administration for increased U.S. investment to fight AIDS. But one year is early in any Administration; President Obama still has the potential to carry forward a bold agenda on global AIDS.

President Obama could earn an “A” if he seizes this opportunity and if he
crafts a budget request for FY2011 that puts U.S. investments in global AIDS back on track—and includes prominent support for a bold HIV treatment target to be achieved by 2013. There is urgent need for course correction by U.S. leadership in fight against AIDS.

PRESIDENT OBAMA’S GLOBAL AIDS PROMISES

As a Presidential candidate and as a Senator, President Obama made bold commitments to tackle global AIDS, and followed through on those promises with legislation passed just before the 2008 Presidential election. For example, on World AIDS Day in 2007, Senator Obama pledged to “provide $50 billion by 2013 to fight the pandemic, and
contribute our fair share to the Global Fund.”

He also pledged to “at least double the number of HIV-positive people on treatment.”5 As a Senator he backed this pledge with legislation that would authorize $48 billion in spending for PEPFAR by 2013; this legislation was signed into law by President Bush in 2008, just months before Obama was elected President.

Obama’s global AIDS platform was coupled with a public commitment to double foreign assistance in order to combat poverty that increases vulnerability to HIV infection and AIDS-related death.

Since taking office, however, President Obama has failed to keep these promises—despite tremendous potential.

After one year in office we can assess in four critical areas the performance of the Administration:

1) U.S. global AIDS funding levels;

2) U.S.-supported HIV treatment scale up efforts;

3) effective HIV prevention; and

4) linkages between AIDS programs and U.S. global health programs supporting primary health care in developing countries.

U.S. FUNDING FOR GLOBAL AIDS:

Despite repeated public commitments to expand funding for successful global AIDS programs, the first budget request to Congress prepared by President Obama, for FY2010, would essentially flat-fund U.S. global AIDS investments—this budget request would not even keep pace
with the estimated rate of global medical inflation (4-10% for 2009).

Specifically, President Obama requested a slight increase in bilateral AIDS funding, but requested a cut of the same amount for the Global Fund. At the country level, flatlining in Washington is translating into actual budget cuts in many programs, sending shock waves through communities and calling into question the sincerity of the Administration’s commitment to reaching the coverage levels promised
under the 2008 Lantos-Hyde Act, which passed with overwhelming
bipartisan support and was cosponsored by then-Senators Obama,
Clinton, and Biden. Administration officials have signaled that they will likely request the same in FY2011 as 2010—a roughly 2 percent increase.

These budget requests contrast starkly with the funding trajectory required to conform with the Lantos-Hyde Act spending levels
President Obama promised to reach (see graph and text box in original publication).

U.S. COMMITMENT TO TREATMENT SCALE-UP:

Worldwide, roughly 10 million of the 33 million people who are HIV
positive face death in the next two years if they do not initiate treatment urgently. Of those 10 million, approximately 60 percent
still lack treatment access. The Lantos-Hyde Act committed the U.S. to continue an ambitious scale-up of AIDS treatment through 2013, expanding access as funding increased and the cost of HIV treatment fell. As the graph below shows, the number of people living with HIV on treatment has historically tracked directly to the funding available. The impact of
AIDS funding as a result of the last budget prepared by the lame duck Bush Administration, for FY2009, will be announced shortly and will likely include reaching about an addition 1 million people on AIDS treatment—or 3 million total.

Increasing resources could enable President Obama to make good on his campaign promise to double the number of people on AIDS treatment—to 6 million people by 2013.9 However, the Obama Administration’s flat-lined funding for global AIDS undermines his commitment to fund the U.S. fair share of the AIDS treatment burden.

Already, reports are emerging of clinic waiting lists rapidly expanding, and clinics being forced to turn away patients due to lack of promised funding. Dr. Peter Mugyenyi, the director of one of Uganda’s leading AIDS clinics recently stated, “Soon we fear the carnage of AIDS will once again surge and the obvious success we have seen of PEPFAR may begin to be reversed.”10 Access to life-saving therapies has revolutionized the AIDS response in developing countries, resulting in millions of lives saved.

Simultaneously, HIV prevention has been strengthened and become more accessible to vulnerable communities—decreased stigma brought about by treatment access means more people are willing to know their HIV status. In addition, epidemiologists predict that expansion of AIDS treatment will directly avert infections as people and populations
become less infectious.

Finally, the rapid scale up of chronic disease management in the most impoverished parts of the world has laid the groundwork for scaling up overall public health service delivery—creating important opportunities to strengthen reproductive health, decrease maternal, newborn and child mortality, and address other community health priorities.12 WHO’s improved adult HIV treatment guidelines—released today—endorse the use of less toxic antiretroviral therapy, and the initiation of treatment at an earlier stage of HIV infection.

Rapid implementation of these guidelines will dramatically improve the impact and durability of the treatment response—but will be impossible unless President Obama and the Congress keep their AIDS
funding promises.

U.S. COMMITMENT TO EFFECTIVE, COMPREHENSIVE HIV PREVENTION:

As a candidate, President Obama promised to break away from the Bush Administration’s ideologically-driven HIV prevention programs that disregarded science and evidence, and that required PEPFAR recipient countries to scale up abstinence-only-until-marriage prevention
programs despite evidence that they were ineffective.

Admirably, by rescinding the Global Gag Rule, President Obama ended restrictions on U.S. funding for organizations that provide family planning services and that are often the first responders for women in the fight against HIV. He also re-instated funding to the United Nations Population Fund, a UN agency that provides critical support for sexual and reproductive health care, including HIV and AIDS, throughout the world.

Access to comprehensive reproductive health care services provides life- saving information and services to prevent the sexual transmission of HIV as well as unintended pregnancy. Since taking office, the Obama Administration has clearly stated its commitment to addressing the linkages between reproductive health and HIV and AIDS in the fight to
prevent sexual transmission of HIV and vertical transmission of HIV from mothers to their children—which was underscored in the newest policy guidance provided by PEPFAR headquarters to country teams.

However, PEPFAR has not produced country guidance that clearly directs countries toward funding comprehensive HIV prevention services. In
addition, countries that do not spend the majority of funding for sexual prevention activities on “abstinence-only-until-marriage” and “being faithful” programming are still required to explain those decisions. In fact, this so-called “soft earmark” is now associated with an essential PEPFAR indicator that all countries must report to PEPFAR headquarters
on—the numbers of people reached with “interventions that are primarily focused on abstinence and/or being-faithful.”

In addition, President Obama has pledged to lift restrictions on funding needle exchange programs in the U.S. and overseas. However, for PEPFAR programs those restrictions would not require a change in U.S. law—only a change in PEPFAR policy guidance to countries. Nevertheless the Administration has not authorized that change.

U.S. COMMITMENT TO EXPANDING GLOBAL HEALTH INVESTMENTS:

President Obama pledged to expand investments in global health programs as a feature of U.S. foreign policy. Investments in reproductive, maternal, newborn and child health, neglected tropical diseases, and other health priorities are much needed and would bolster the health of people living with HIV around the world. In May 2009, the White House announced a “Global Health Initiative.”

The details of this six-year program remain vague, however a coalition of leading US-based global health organizations point out that the current $63 billion price tag touted by the White House will not be sufficient to reach the goals envisioned—instead an estimated $95 billion over six years would be needed.16 Lantos-Hyde Act spending for AIDS, tuberculosis and malaria programs is pledged at $48 billion over five years; a $63 billion health initiative over six years means significant increases in other health priorities would have to come at the expense of infectious disease investments—or not at all.

With AIDS as the number one killer of women of reproductive age around the world, tackling maternal mortality and child health requires expansion of HIV treatment and prevention programs and simultaneous expansion of other women’s health priorities.

CONCLUSION

In his first year in office, President Obama has all but failed to fulfill his commitments to wage an aggressive battle against global AIDS. Signs of policy shifts toward science-based prevention are most welcome, as is the President’s progress on lifting of the ban on people living with HIV traveling or immigrating to the U.S. However, this cannot mask the failure—so far—to chart a course that fully funds the U.S. response against global AIDS and ensures policy changes that were promised, are kept. Leading up to the State of the Union and the release of the FY2011 budget in February 2010, President Obama should take the following steps in order to make the urgent course correction needed:

  • Fulfill promises on funding: This means not flat-funding AIDS in FY2011 but instead increasing funding to $7.25 billion for PEPFAR and $2 billion for the Global Fund. This would put the President back on track reaching the Congressional Lantos-Hyde Act authorization of $48 billion for AIDS, tuberculosis, and malaria by 2013—including $39 billion for HIV. In addition to bilateral aid, the Administration should also support the establishment of a tax on currency transactions for health, a straightforward way to raise substantial new resources, and a move that was recently endorsed by several G8 country governments.  Finally, the Obama Administration should help ensure that U.S. funding is truly additional, by supporting liberalization of IMF macroeconomic policies.
  • Set a goal to double the number of people on treatment to 6 million by 2013: The Bush lame-duck budget will have financed an expansion to nearly 3 million people on treatment by this year. Doubling treatment coverage to 6 million is possible—and would put the U.S. on track to treat roughly one-third of those in need under new WHO guidelines announced today.
  • Real support to evidence-based prevention: The Administration should launch a full review of its prevention portfolio and eliminate funding for prevention programs that are not evidence based, such as abstinence-only programs. It should immediately issue new guidance to all programs focused on science and evidence. It must also lift the policy barriers to proven health interventions such as syringe exchange.

 

Analysis Politics

The 2016 Republican Platform Is Riddled With Conservative Abortion Myths

Ally Boguhn

Anti-choice activists and leaders have embraced the Republican platform, which relies on a series of falsehoods about reproductive health care.

Republicans voted to ratify their 2016 platform this week, codifying what many deem one of the most extreme platforms ever accepted by the party.

“Platforms are traditionally written by and for the party faithful and largely ignored by everyone else,” wrote the New York Times‘ editorial board Monday. “But this year, the Republicans are putting out an agenda that demands notice.”

“It is as though, rather than trying to reconcile Mr. Trump’s heretical views with conservative orthodoxy, the writers of the platform simply opted to go with the most extreme version of every position,” it continued. “Tailored to Mr. Trump’s impulsive bluster, this document lays bare just how much the G.O.P. is driven by a regressive, extremist inner core.”

Tucked away in the 66-page document accepted by Republicans as their official guide to “the Party’s principles and policies” are countless resolutions that seem to back up the Times‘ assertion that the platform is “the most extreme” ever put forth by the party, including: rolling back marriage equalitydeclaring pornography a “public health crisis”; and codifying the Hyde Amendment to permanently block federal funding for abortion.

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Anti-choice activists and leaders have embraced the platform, which the Susan B. Anthony List deemed the “Most Pro-life Platform Ever” in a press release upon the GOP’s Monday vote at the convention. “The Republican platform has always been strong when it comes to protecting unborn children, their mothers, and the conscience rights of pro-life Americans,” said the organization’s president, Marjorie Dannenfelser, in a statement. “The platform ratified today takes that stand from good to great.”  

Operation Rescue, an organization known for its radical tactics and links to violence, similarly declared the platform a “victory,” noting its inclusion of so-called personhood language, which could ban abortion and many forms of contraception. “We are celebrating today on the streets of Cleveland. We got everything we have asked for in the party platform,” said Troy Newman, president of Operation Rescue, in a statement posted to the group’s website.

But what stands out most in the Republicans’ document is the series of falsehoods and myths relied upon to push their conservative agenda. Here are just a few of the most egregious pieces of misinformation about abortion to be found within the pages of the 2016 platform:

Myth #1: Planned Parenthood Profits From Fetal Tissue Donations

Featured in multiple sections of the Republican platform is the tired and repeatedly debunked claim that Planned Parenthood profits from fetal tissue donations. In the subsection on “protecting human life,” the platform says:

We oppose the use of public funds to perform or promote abortion or to fund organizations, like Planned Parenthood, so long as they provide or refer for elective abortions or sell fetal body parts rather than provide healthcare. We urge all states and Congress to make it a crime to acquire, transfer, or sell fetal tissues from elective abortions for research, and we call on Congress to enact a ban on any sale of fetal body parts. In the meantime, we call on Congress to ban the practice of misleading women on so-called fetal harvesting consent forms, a fact revealed by a 2015 investigation. We will not fund or subsidize healthcare that includes abortion coverage.

Later in the document, under a section titled “Preserving Medicare and Medicaid,” the platform again asserts that abortion providers are selling “the body parts of aborted children”—presumably again referring to the controversy surrounding Planned Parenthood:

We respect the states’ authority and flexibility to exclude abortion providers from federal programs such as Medicaid and other healthcare and family planning programs so long as they continue to perform or refer for elective abortions or sell the body parts of aborted children.

The platform appears to reference the widely discredited videos produced by anti-choice organization Center for Medical Progress (CMP) as part of its smear campaign against Planned Parenthood. The videos were deceptively edited, as Rewire has extensively reported. CMP’s leader David Daleiden is currently under federal indictment for tampering with government documents in connection with obtaining the footage. Republicans have nonetheless steadfastly clung to the group’s claims in an effort to block access to reproductive health care.

Since CMP began releasing its videos last year, 13 state and three congressional inquiries into allegations based on the videos have turned up no evidence of wrongdoing on behalf of Planned Parenthood.

Dawn Laguens, executive vice president of Planned Parenthood Action Fund—which has endorsed Hillary Clinton—called the Republicans’ inclusion of CMP’s allegation in their platform “despicable” in a statement to the Huffington Post. “This isn’t just an attack on Planned Parenthood health centers,” said Laguens. “It’s an attack on the millions of patients who rely on Planned Parenthood each year for basic health care. It’s an attack on the brave doctors and nurses who have been facing down violent rhetoric and threats just to provide people with cancer screenings, birth control, and well-woman exams.”

Myth #2: The Supreme Court Struck Down “Commonsense” Laws About “Basic Health and Safety” in Whole Woman’s Health v. Hellerstedt

In the section focusing on the party’s opposition to abortion, the GOP’s platform also reaffirms their commitment to targeted regulation of abortion providers (TRAP) laws. According to the platform:

We salute the many states that now protect women and girls through laws requiring informed consent, parental consent, waiting periods, and clinic regulation. We condemn the Supreme Court’s activist decision in Whole Woman’s Health v. Hellerstedt striking down commonsense Texas laws providing for basic health and safety standards in abortion clinics.

The idea that TRAP laws, such as those struck down by the recent Supreme Court decision in Whole Woman’s Health, are solely for protecting women and keeping them safe is just as common among conservatives as it is false. However, as Rewire explained when Paul Ryan agreed with a nearly identical claim last week about Texas’ clinic regulations, “the provisions of the law in question were not about keeping anybody safe”:

As Justice Stephen Breyer noted in the opinion declaring them unconstitutional, “When directly asked at oral argument whether Texas knew of a single instance in which the new requirement would have helped even one woman obtain better treatment, Texas admitted that there was no evidence in the record of such a case.”

All the provisions actually did, according to Breyer on behalf of the Court majority, was put “a substantial obstacle in the path of women seeking a previability abortion,” and “constitute an undue burden on abortion access.”

Myth #3: 20-Week Abortion Bans Are Justified By “Current Medical Research” Suggesting That Is When a Fetus Can Feel Pain

The platform went on to point to Republicans’ Pain-Capable Unborn Child Protection Act, a piece of anti-choice legislation already passed in several states that, if approved in Congress, would create a federal ban on abortion after 20 weeks based on junk science claiming fetuses can feel pain at that point in pregnancy:

Over a dozen states have passed Pain-Capable Unborn Child Protection Acts prohibiting abortion after twenty weeks, the point at which current medical research shows that unborn babies can feel excruciating pain during abortions, and we call on Congress to enact the federal version.

Major medical groups and experts, however, agree that a fetus has not developed to the point where it can feel pain until the third trimester. According to a 2013 letter from the American Congress of Obstetricians and Gynecologists, “A rigorous 2005 scientific review of evidence published in the Journal of the American Medical Association (JAMA) concluded that fetal perception of pain is unlikely before the third trimester,” which begins around the 28th week of pregnancy. A 2010 review of the scientific evidence on the issue conducted by the British Royal College of Obstetricians and Gynaecologists similarly found “that the fetus cannot experience pain in any sense prior” to 24 weeks’ gestation.

Doctors who testify otherwise often have a history of anti-choice activism. For example, a letter read aloud during a debate over West Virginia’s ultimately failed 20-week abortion ban was drafted by Dr. Byron Calhoun, who was caught lying about the number of abortion-related complications he saw in Charleston.

Myth #4: Abortion “Endangers the Health and Well-being of Women”

In an apparent effort to criticize the Affordable Care Act for promoting “the notion of abortion as healthcare,” the platform baselessly claimed that abortion “endangers the health and well-being” of those who receive care:

Through Obamacare, the current Administration has promoted the notion of abortion as healthcare. We, however, affirm the dignity of women by protecting the sanctity of human life. Numerous studies have shown that abortion endangers the health and well-being of women, and we stand firmly against it.

Scientific evidence overwhelmingly supports the conclusion that abortion is safe. Research shows that a first-trimester abortion carries less than 0.05 percent risk of major complications, according to the Guttmacher Institute, and “pose[s] virtually no long-term risk of problems such as infertility, ectopic pregnancy, spontaneous abortion (miscarriage) or birth defect, and little or no risk of preterm or low-birth-weight deliveries.”

There is similarly no evidence to back up the GOP’s claim that abortion endangers the well-being of women. A 2008 study from the American Psychological Association’s Task Force on Mental Health and Abortion, an expansive analysis on current research regarding the issue, found that while those who have an abortion may experience a variety of feelings, “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors.”

As is the case for many of the anti-abortion myths perpetuated within the platform, many of the so-called experts who claim there is a link between abortion and mental illness are discredited anti-choice activists.

Myth #5: Mifepristone, a Drug Used for Medical Abortions, Is “Dangerous”

Both anti-choice activists and conservative Republicans have been vocal opponents of the Food and Drug Administration (FDA’s) March update to the regulations for mifepristone, a drug also known as Mifeprex and RU-486 that is used in medication abortions. However, in this year’s platform, the GOP goes a step further to claim that both the drug and its general approval by the FDA are “dangerous”:

We believe the FDA’s approval of Mifeprex, a dangerous abortifacient formerly known as RU-486, threatens women’s health, as does the agency’s endorsement of over-the-counter sales of powerful contraceptives without a physician’s recommendation. We support cutting federal and state funding for entities that endanger women’s health by performing abortions in a manner inconsistent with federal or state law.

Studies, however, have overwhelmingly found mifepristone to be safe. In fact, the Association of Reproductive Health Professionals says mifepristone “is safer than acetaminophen,” aspirin, and Viagra. When the FDA conducted a 2011 post-market study of those who have used the drug since it was approved by the agency, they found that more than 1.5 million women in the U.S. had used it to end a pregnancy, only 2,200 of whom had experienced an “adverse event” after.

The platform also appears to reference the FDA’s approval of making emergency contraception such as Plan B available over the counter, claiming that it too is a threat to women’s health. However, studies show that emergency contraception is safe and effective at preventing pregnancy. According to the World Health Organization, side effects are “uncommon and generally mild.”

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.