Dr. Babatunde Osotimehin of UNFPA writes about Population in Science Magazine

Jane Roberts

The cover story of the July 29, 2011 issue of Science Magazine is Population. We learn that in 1900 there were 1.6 billion human beings, 3 billion in 1960, and that the world will reach the benchmark of 7 billion this year.

The cover story of the July 29, 2011 issue of Science Magazine is Population. We learn that in 1900 there were 1.6 billion human beings, 3 billion in 1960, and that the world will reach the benchmark of 7 billion this year. The world is gaining 1 billion people every 13 years. We also learn that from 1950 to the present the total fertility rate has fallen from 5 children per woman to 2.5, a remarkable achievement. But we also learn that the Population Division of the United Nations predicts a human population of slightly more than 9 billion by 2050. I promise you that every one of those human beings will come out of the womb of a woman. I promise you that such a human population will have huge trouble spots or, as the Population section defines them “cluster bombs” (Nigeria and Pakistan are cited) where population will outpace food, water, and other resources. Humanitarian crises will abound.

Dr. Babatunde Osotimehin, the new Executive Director of the United Nations Population Fund (UNFPA) writes the lead editorial. He cites the fact of there being 584 million adolescent girls and that 88 percent of them live in developing countries. He cites the United Nations Adolescent Girls Task Force, the Partnership for Maternal, Newborn, and Child Health (PMNCH of which our grassroots movement 34 Million Friends of UNFPA is a member), the Global Strategy on Women’s and Children’s Health and in Africa the Campaign for Accelerated Reduction of Maternal Mortality as evidence of the world’s recognition of the centrality of girls’ and women’s access to education, health and human rights to an acceptable future for people and the planet.

Under the heading “Does Family Planning Bring Down Fertility?” Lant Pritchett, former World Bank economist and professor at Harvard, says that money is better spent on girls’ education than on family planning because the strongest predictors of fertility are income, education, and infant and child survival rates. University of California lecturer Martha Campbell (a personal friend) counters that in some places fertility is so high that building adequate educational infrastructure falls behind and that in addition, being able to space children improves the health of both mothers and babies. I side with her and want to add that most countries could, with a change in budgetary priorities do both. And foreign assistance from the developed world spends minuscule amounts targeting girls. This has to change. Hillary Clinton is working on just that.

One more thing about family planning. When it is offered to women without their husbands being present, their fertility rates fall more than that of women who are accompanied by their husbands. No surprise there!

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I would like to recommend one video and one article. The 80 second video put together by Population Action International (www.empty-handed.org) shows real women seeking but not finding access to contraception and the devastating effect it has on their lives. The article “Women’s Health Equals Global Health” is mine and can be found on the home page highlighted in orange at www.34millionfriends.org.

The one thing I regret  in such a “scientific” treatment of population is the dry tone. After all population means real people. But to balance that mild criticism there are “Regional Snapshots” where you see real people’s real lives.

Some parts of this Science Magazine issue are available on line at www.aaas.org.

Commentary Health Systems

Texas Is About to Overhaul Its Entire Social Safety Net: Explained, in GIFs

Andrea Grimes

This year, Texas’ Health and Human Services Commission, and the departments it oversees, are up for review by the Sunset Advisory Commission. It can't hurt to start amassing your "fingers crossed" GIFs now.

When the Texas legislature convenes in January, it will be tasked with retooling—and perhaps entirely overhauling—the state’s sprawling Health and Human Services Commission, a five-armed behemoth that oversees everything from Medicaid, children’s Medicaid, and Medicaid fraud to foster care, disability services, family planning, mental and behavioral health care, vital statistics, food safety, infectious disease prevention, food stamps, and dozens of other services predominantly intended to address the needs of Texas’ most marginalized and vulnerable residents.

Yeah, it’s a lot. I say HHSC is “intended to address the needs” of the most vulnerable Texans, and the health and safety of Texans writ large, because intent does not necessarily follow into execution where the state’s health department is concerned.

In theory, the wide-reaching HHSC is supposed to operate in an orderly bureaucratic fashion. Like so:

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In practice, things have turned out to look a little more like this:

This is where the state’s Sunset Advisory Commission comes in. The 12-member commissioncomprised of ten lawmakers (three Democrats and seven Republicans) and two “public members”—reviews the work of all manner of state agencies and departments when their statutory “sunset” time comes. It sounds very romantic, no?

But it’s often more like:

State agencies generate reports based on the work of their own staffers; meanwhile, the Sunset Advisory Commission generates its own report based on a separate review of an agency’s work, and also members of the public and interested stakeholders are invited to provide suggestions on the future operations of Texas bureaucracies.

Throughout the process, the Sunset Advisory Commission holds a load of meetings and ultimately makes a passel of recommendations based on all this input, and they pass along the recommendations to Texas lawmakers, who are then tasked with drawing up legislation to enact (or not) changes to various state departments and agencies. Order is restored!

You know there’s another “but actually” panic GIF coming here in a minute, don’t you? You’re so smart. Waaaaaaaaaaaait for it.

This year, Texas’ Health and Human Services Commission, and the departments it oversees, are up for Sunset review. We’re talking about a department with a budget of $34.5 billion, which employs 54,000 people, and which has been tasked with weaving, maintaining, and patching the state’s social services safety net, while also figuring out how best to pay for it all with the resources that lawmakers allocate to it.

The agency has not, shall we say, done a stellar job so far. To find out why and how that is, you can peruse the 461-page HHSC staff report delivered to Sunset, which details its operations, challenges, and suggestions for improvement. Or here are 217 equally riveting pages, generated by the Sunset Advisory Commission itself, on what it says are HHSC’s many and various faults and failures.

Stop! No! You don’t have to read it all. Kind of the main takeaway from the whole 600+ page shebang is that Texas’ entire health and social services delivery apparatus has more or less failed do what the last Sunset Advisory Commission told it to do, way back in 2003.

Right. So back then, Texas’ Health and Human Services operated under 12 agencies and with 200 divisions.

On the recommendation of that past Sunset commission, the Texas legislature consolidated the agency into the five departments and commissions that oversee, provide, audit, and collect fees for services today. Those agencies are the Department of Assistive and Rehabilitative Services, the Department of Aging and Disability Services, the Department of Family and Protective Services, the Department of State Health Services and the Health and Human Services Commission, which oversees the other four and is tasked with implementing Medicaid services.

I’ll let you decide which member of One Direction you want to imagine represents each entity.

The current problem is not that the Health and Human Services Commission and its various departments aren’t doing any of their jobs, or that they aren’t doing a few of them adequately. It’s that HHSC has had 11 years to streamline its bureaucratic processes according to legislative and statutory directives and has only sort of done some of that, and there’s a lot of confusion and overlap in terms of which services are available from which departments, and a lot of folks—particularly people who need and receive services—don’t know who to hold accountable when shit goes awry.

And the Texans who need HHSC? Tend to be people who are already marginalized in the wider community—people who are very low-income with mental health or physical assistance needs, who need public aid to feed their families and so on—and who don’t always have the time, ability, or resources to be able to squeeze what they need out of an overburdened staff who, really truly and genuinely most of the time, are trying to do their jobs. But even they get confused too.

Who else is confused? The Sunset Advisory Commission itself, apparently, which included this gem of a paragraph in its December 2014 report on HHSC:

The problem is not with the concept of consolidation. Nor is the problem with the energetic, capable commissioners or the hard-working, dedicated employees at the agencies. The problem is with the nature of the system itself, and the incompleteness of its set up. The problem is that for whatever reason, the state did not finish the job.

For whatever reason.

Sunset’s idea now is to do more consolidation, because there was not enough consolidation happening before, 11 years ago, the last time that Sunset wanted HHSC to do consolidation, which it didn’t really do very well. Now that HHSC has not done the consolidation it was asked to do previously, Sunset would like HHSC to consolidate further.

Specifically, Sunset has recommended folding the five-part agency into one entity, under one HHSC executive office, with seven divisions: the Office of the Inspector General (which investigates fraud), Medical and Social Services (stuff like family planning, food stamps, disability services), State Institutions and Facilities (state-supported nursing homes, state hospitals, etc.), Family and Protective Services (adult and child protective services), Centralized Services (IT and human resources type stuff), Public Health Services (disease prevention, public health labs, vital statistics), and Regulatory (food and drug safety, abuse investigations, child care licensing).

So Sunset now wants more consolidation on top of the consolidation that already wasn’t really done, for “whatever reason.”

Of course, it’s possible that one of the “whatever reasons” that HHSC can’t seem to get it together is that Texas lawmakers have a rather pointed tendency to shift and modify HHSC’s responsibilities and requirements depending on which way the political winds are blowing. Recently, you may have noticed those winds blowing in a, let’s say, rightwardly fashion. Let’s take family planning care as an example.

In the mid-aughts, Texas launched its Medicaid Women’s Health Program, because family planning investments save a shitload of money for taxpayers and it’s always nice when low-income folks can plan their families the same way wealthier people with private insurance plans can. Great move, Texas lawmakers!

But in 2011, spurred on by Tea Party lawmakers, the legislature changed its mind about that whole “treat low-income people like humans” thing and slashed public family planning dollars by two-thirds and went on a big crusade against Planned Parenthood and banned it—the most efficient and cost-effective provider of family planning services to low-income Texans—from participating in the provision of family planning services for people who receive publicly funded assistance. Because America!

But since you can’t actually like, legally do that, according to the pesky ol’ Social Security Act, the federal government cut off its nine-to-one funding match for the Medicaid Women’s Health Program and the state created a new, entirely state-funded Texas Women’s Health Program (TWHP). The TWHP is technically administered under the umbrella of the Health and Human Services Commission but its subsidiary, the Department of State Health Services, actually does the majority of work on implementing it.

Hold on, it gets better. In 2013, the Texas legislature, having realized that it sort of crapped the bed cutting all that money to family planning in 2011—as a result of those funding cuts, dozens of family planning clinics, only a few of them Planned Parenthood clinics, shuttered or drastically reduced services—reallocated some state money to a new Expanded Primary Health Care (EPHC) program which is supposed to include general preventive care in addition to family planning care like contraception and cancer screenings. But the EPHC doesn’t actually include any statutory mandates or accountability review capacity that ensures anybody is actually getting any family planning services as part of the EPHC.

Then, the federal government decided, for the first time in decades, to award Title X family planning dollars not to the Department of State Health Services, but to an independent coalition of family planning providers. So DSHS lost that revenue stream too.

In sum, this whole series of events was touted as a family planning “advance” by lawmakers like Sen. Jane Nelson, herself a prominent presence on the Sunset Advisory Commission.

Meanwhile, everyone who knows literally anything about family planning—it doesn’t even have to be the first thing—has been all:

So what we have here, with today’s Sunset Advisory Commission, is an opportunity to streamline three different family planning programs, all operating under different divisions of HHSC but which now garner almost all of their funding from Texas’ general revenue fund: the Texas Women’s Health Program under HHSC, the generic state family planning program and the EPHC, both under DSHS. From the Sunset commission’s own report:

Constant changes in state women’s health policies over the past four years have made stakeholders weary of revisiting an issue so fraught with controversy and emotion. As understandable as these concerns are, the state cannot afford to continue such a fragmented approach that is so difficult to navigate.

Probably you’re reading this and you’re imagining an ever-more-conservative Texas legislature, seething with tri-corner hats and tea bags following the midterm elections, getting further hold on what’s left of our state’s family planning apparatus.

Don’t panic. A number of organizations, researchers, and advocacy groups that work in and on family planning services have made some very smart recommendations to the Sunset Advisory Commission that even align, in part, with what the commission itself would like to see happen within HHSC when it comes to family planning services.

Yes, really! Rewire talked to representatives from both the Texas Policy Evaluation Project (TxPEP), a university-based research group that tracks the impact of family planning policies in Texas, and the National Latina Institute for Reproductive Health (NLIRH), which produced the invaluable Nuestro Texas report, along with the Center for Reproductive Rights, detailing how those policies have affected Latinas in the Rio Grande Valley, and they’re cautiously optimistic about the future of HHSC and family planning.

Both groups made recommendations to the Sunset commission that included tentative support for consolidation, as well as support for expanding income and age eligibility requirements, allowing Texans who have been sterilized to obtain reproductive health-care services, advocating for on-site enrollment and program eligibility determinations made at the point of care, and increasing the affordability and availability of long-acting reversible contraceptives (LARCs).

NLIRH has also proposed exploring the possibility of operating mobile reproductive health-care clinics and allowing Texans between ages 15 and 18 to get contraception without parental consent. TxPEP has also suggested cost-reimbursement services, in addition to fee-for-service structures, and a “new method of evaluating family planning programs in Texas” that shifts from a cost-per-client evaluation to an estimation of the “cost per year of protection from unintended pregnancy,” which would better measure the return on investment for initially costly, but long-term and highly effective, LARCs.

What is key—and NLIRH makes this plain in its Sunset recommendations—is that stakeholders and patients have the opportunity to participate in the transition process toward a more consolidated family planning delivery system:

NLIRH recommends for the process of consolidation to include substantial, meaningful, and ongoing stakeholder involvement from providers and constituents most affected by recent disruptions to the reproductive health safety net. Accordingly, stakeholders should include Latinas, rural women, young people, LGBT populations, and other disproportionately impacted populations in all stages of planning, implementation, and evaluation of proposed changes to state women’s health services.

But the reality is that family planning as an issue has become heavily politicized in Texas, and, well …

Conservative and anti-choice lawmakers have shown, again and again, that they can always find new ways to marginalize and disenfranchise the most vulnerable Texans when it comes to access to family planning care. While TxPEP and NLIRH’s suggestions, along with the Sunset commission’s recommendations, include logical, money-saving efforts to streamline services and reduce reproductive cancers and unplanned pregnancies, there’s really no telling what the legislature might do with them.

And family planning services are just one small part of everything HHSC and its departments do. Texas’ mental health services delivery system, its disability services, and state-provided care for senior citizens are all about to be at the mercy of the Texas legislature. And the list goes on: Under particular scrutiny is the Office of the Inspector General, a vital division that oversees Medicaid fraud and has the ability to recoup millions in savings for Texas, but has been roundly criticized for its inefficiency, lack of oversight, and overall incompetency.

Here’s the Sunset commission on the OIG blunders:

The absence of standard tools such as priorities and criteria to guide the work, and a general reluctance to reach out to the other parts of the health and human services system or to providers and other stakeholders fuels a perception that OIG makes up the rules as it goes to back its “gotcha” approach.

The burn? It burns.

There’s also the question of how to manage the incredible amount of data—”double the amount of everything the Hubble Telescope has sent to Earth”—that HHSC and its agencies have generated over the years.

Here’s Sunset on that gigantic-pants ordeal:

However, the system’s highly decentralized approach to data management prevents basic, appropriate uses of information to measure performance and inform key policy decisions. Fragmentation in oversight also creates risk considering the complicated privacy laws and other regulations governing the data, much of which contains protected personal information.

And hey guess what else is pretty screwed up? Medicaid enrollment. Because of course it is. Sunset’s take:

The state’s lengthy and cumbersome Medicaid enrollment processes and its disconnect with managed care organizations’ credentialing processes cause providers to submit the same information multiple times to numerous different entities to participate in Medicaid, creating an administrative burden for providers and delaying services to clients.

And hey, I don’t know, how about those eleventy different websites and hotlines that are supposed to make HHSC easier to navigate? Let’s go to Sunset for the recap:

HHSC’s statutory requirement to ensure the public can easily find information and interact with health and human services programs through the Internet has led to the five system agencies developing about 100 websites and maintaining 28 separate hotlines.

But at least it’s easy to give feedback to the folks in charge, right? Right, Sunset? RIGHT?

HHSC oversees 41 advisory committees, 35 of which are in statute, to allow stakeholders and members of the public to provide input to the agency. However, the numerous advisory committees create an administrative burden to HHSC staff and their presence in statute can prevent the agency from responding to evolving needs.

Going forward, the Texas legislature has a gargantuan task ahead of it, and the most vulnerable Texans are the ones who will be most affected by the decisions made by the 84th Texas Legislature and its two new leaders, governor-elect Greg Abbott, and lieutenant governor-elect Dan Patrick.

The biggest question will be whether the legislature will remake the agency into the seven-part “mega-agency” recommended by Sunset … and whether the resulting bureaucracy will look anything like this:

Can’t hurt to start amassing your “fingers crossed” GIFs now.

Commentary Law and Policy

On Eve of “Fortnight of Freedom,” North Dakota Votes By Wide Margin to Maintain Firewall Between Religion and Health Care

Jodi Jacobson

Last night, the voters of North Dakota decisively defeated a ballot initiative that one news outlet called an "ecclesiastical mugging." By a margin of 64 percent to 36 percent, voters said "no" to an effort to impose religious doctrine on health care, social policy, and law in the state.

An error contained in this article was corrected at 1:07 pm on Wednesday, June  13th, 2012. The correction, of the percentage share of the vote against Measure 3, appears in the article.

For all the hand-wringing in national polls about what share of the population identifies as “pro-choice” and what share “pro-life,” large majorities of voters in one conservative state after another have shown, resoundingly, that they have no desire to interfere in the personal health concerns or religious decisions of their neighbors.

Voters in South Dakota have twice rejected attempts to impose abortion bans via ballot initiatives. In 2010, voters in Colorado decisively rejected efforts to define a fertilized egg as a person, a step that would have conveyed more rights onto a fertilized egg before pregnancy was even established than on the woman in whose body it floated. A similar so-called personhood initiative was also soundly defeated in Mississippi last fall, again by a large majority of voters.

Now, another conservative state has delivered a huge win in the effort to keep religious ideology out of personal medical decisions. Yesterday, by a margin of 69 66 percent to 34 percent, voters in North Dakota could not have been clearer in rejecting Measure 3, a ballot initiative promoted by, among others, the United States Conference of Catholic Bishop (USCCB), whose Orwellian campaign to promote “religious freedom” actually seeks to impose strict Catholic doctrine on everyone, no matter their professed religious affiliation (or lack thereof), via state and federal law. An editorial on Measure 3 in the North Dakota news site, Inforum, called the effort by the USCCB to pass it “an ecclesiastical mugging.”

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Laws such as Measure 3 are being pursued by religious fundamentalists throughout the country, and they have profound implications for the health and rights of individuals, and for public health. Measure 3, for example, would have allowed physicians, nurses, and pharmacists to refuse to provide care and medication which “conflicts with their religious beliefs,” and would have extended “conscience protections” to virtually any employee of any medical facility, ensuring that one reilgious belief could prevail over another in the realm of health care. Measure 3, according to NARAL Pro-Choice America, would also have allowed “a man to claim that domestic-violence and child-abuse laws don’t apply to him because his religion tells him he has the right to discipline his wife and children as he sees fit,” and would have allowed employers to use their personal religious beliefs to discriminate against their female employees by denying contraceptive coverage under insurance plans.

Inforum noted:

Proponents of the measure insist the language is clear and ironclad. But respected lawyers and retired jurists who have analyzed the language disagree. They have concluded the measure is so vague and so broad that it opens the door wide to individual and organizational interpretations of “religious liberty” that would result in dire consequences.

And like many other such efforts by the far right to pass laws, Measure 3 was “a dangerous solution in search of a nonexistent problem,” according to the Inforum editorial.

When pressed to cite one – just one – example of denied or even attenuated religious liberty in North Dakota, measure supporters come up empty. There are few states where religious liberty is practiced as openly and frequently as North Dakota. Churches and religious-based organizations do vital and excellent work every day in adoption, refugee resettlement, missions, health care, community service and faith-based education. The spiritual lives of North Dakotans who chose a spiritual life – as most do – are sound and secure.

Measure 3 threatens that honorable heritage and history. It’s a self-serving scheme that has the potential to deeply divide people of faith, and thus undermine religious liberty, not protect it. Vote “no.” 

The win in North Dakota, noted NARAL, “marks the 10th pro-choice victory out of the 11 ballot measures affecting reproductive rights that have appeared before voters since 2005.”

“The message to anti-choice groups is clear,” stated Nancy Keenan, president of NARAL Pro-Choice America, “voters are tired of your divisive attacks that undermine the fundamental American values of freedom and privacy.”

The results are no less important because they come on the eve of the USCCB’s “Fornight for Religious Freedom,” during which the Bishops intend, incomprehensibly, to reprise their role as long-suffering victims of religious discrimination if they are not enabled by law to exert complete control over the health care and reproductive choices of individual women and their families.

After the results were in, Sarah Stoesz, President of the Planned Parenthood Minnesota, North Dakota, South Dakota Action Fund, stated:

“Tonight, North Dakotans – with a strong and clear NO vote – affirmed that religious liberty is securely protected in the US Constitution. Measure Three was divisive, unnecessary and could have had dangerous consequences. Tonight’s vote protects state laws against child abuse or neglect, laws against domestic violence, laws that affect access to health care, including birth control, and laws that ensure equal opportunity in the workplace.”

“We applaud North Dakotans Against Measure Three for working tirelessly to educate voters about the dangerous consequences this amendment could have had for women and families in the state.”

Planned Parenthood joined with a number of organizations to defeat Measure 3, including ND Healthy Families Opposing Measure 3, Choice USA, Feminist Majority, and the National Organization for Women. NARAL Pro-Choice America launched a nationwide public-education campaign.

And just as in Mississippi, South Dakota, and Colorado before, North Dakota voters decided that “religious freedom” isn’t compatible with laws mandating that one religious view govern the very health and lives of every person, and most especially women.


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