Texas Policy Evaluation Project
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Texas Women’s Access to Reproductive Health Services Since the 2016 Statewide Reorganization of Women's Health Programs

Kari White, Kristen Burke, Kristine Hopkins, and Joseph E. Potter
June 2019

Nearly one-quarter of adult Texas women are uninsured and approximately one in ten are covered by publicly funded insurance, including Medicaid.1 Over the last 3 years, the state of Texas has reorganized programs that provide family planning services for uninsured and low-income women.

The Healthy Texas Women (HTW) program was created in 2016 to provide contraception and other reproductive health services to Texas resident women who are 15 to 44 years old, US citizens or qualified immigrants, and have incomes at or below 200% of the federal poverty level. It is the third fee-for-service family planning program operated by the state of Texas since 2005.

The Family Planning Program also was redesigned in 2016 and provides a similar range of services to any uninsured Texas resident younger than 64 who has an income at or below 250% of the federal poverty level.

This brief reports on a statewide survey we conducted with 572 Texas resident women aged 18 to 44 who were at risk of an unplanned pregnancy. We asked them about their contraceptive use and experiences accessing reproductive health care in the last 3 years.

We compared experiences for women who had private health insurance, were publicly insured (had Medicaid, HTW or relied on a county-funded program), and those who reported no insurance coverage for women’s health services.

1Kaiser Family Foundation. 2017. “Health insurance coverage for women 19-64.” Available from: https://www.kff.org/other/state-indicator/nonelderly-adult-women/. Accessed May 21, 2019.

Key Findings

  • Uninsured and publicly insured Texas women are less likely than privately insured women to be using their preferred birth control method, especially IUDs, implants, and sterilization.
  • Uninsured and publicly insured Texas women face multiple barriers to accessing women’s health care.
  • 28% of women income-eligible for the Healthy Texas Women (HTW) program are uninsured for women’s health care. 73% of these uninsured, income-eligible women have not heard of HTW.

Many uninsured and publicly insured women are not using their preferred method of contraception

In the survey, we asked women about the method of contraception they were using and the type of birth control they would like to use if they could get any method for free. Overall, less than half of uninsured (46%) and publicly insured (41%) women were using their preferred method of contraception, compared with 59% of privately insured women. Instead, many women, including more than half of uninsured women, relied on less effective contraceptive methods, such as condoms and withdrawal, or were not using any method of birth control (Figure 1).

Figure 1: Uninsured and Publicly Insured* Women are Less Likely To Be Using Their Preferred Contraceptive Method


*Publicly insured women are those whose women’s health services are covered by Medicaid, Healthy Texas Women, or county-funded programs.
1Also includes a small number of women using the vaginal ring and contraceptive patch.

There was a large gap between women’s use of intrauterine devices (IUDs) and contraceptive implants and their preference for using these methods. While 13% of uninsured and publicly insured women were using one of these methods, more than twice as many wanted to be using them. This gap was narrower for privately insured women: 15% were using an IUD or implant and 19% wanted to be using one of these methods. Additionally, more publicly insured women wanted to use a permanent contraceptive method, namely female sterilization and vasectomy, than were relying on these methods.

Barriers to women’s health services are common, particularly for publicly insured and uninsured women

Women encountered multiple barriers to accessing women’s health services – such as contraception and cervical cancer screening – within the last 3 years. Difficulty paying for care was the most common barrier for both uninsured and publicly insured women (Figure 2). Approximately one-third of publicly insured women also reported difficulties finding a provider that accepted their insurance, locating a provider that offered the services they needed, and getting transportation. In contrast, 10% or less of privately insured women reported these difficulties.

Overall, 20% of women reported experiencing three or more barriers accessing women’s health services in the last 3 years. In addition to lacking private insurance coverage, women who experienced three or more barriers accessing care were more likely to have a high school education or less and have incomes <100% of the federal poverty level.

Figure 2: Uninsured and Publicly Insured* Women Commonly Experience Barriers Accessing Women's Health Services

Figure 2

*Publicly insured women are those whose women’s health services are covered by Medicaid, Healthy Texas Women, or county-funded programs.

Some uninsured women are likely eligible for Healthy Texas Women, but many have not heard of the program

Nearly half (47%) of women surveyed reported incomes ≤ 200% of the federal poverty level, which would make them income-eligible for the HTW program. Overall, 11% of these women were already enrolled in the program, 13% had Medicaid, and 38% had private insurance (Figure 3). However, more than one in four income-eligible women remained uninsured. Women who lived in counties that border Mexico, were Hispanic, or had less than a high school education were more likely to be income-eligible for the HTW program but uninsured, and two-thirds of these women had children. Some of these women may be ineligible for the program due to their citizenship or residency status.

Figure 3: Over One Quarter of Women Eligible for the Healthy Texas Women (HTW) Program Do Not Have a Funding Source for Women's Health Services

Figure 3

The survey also asked women if they had heard of HTW. Among uninsured, income-eligible women, 73% had not heard of the program (Figure 4). Uninsured women who did not have children were more likely than those with children to be unaware of the program, but there were no other differences in awareness according to women’s age, race/ethnicity or level of education.

Figure 4: Most Uninsured, Eligible Women Have Not Heard of the Healthy Texas Women (HTW) ProgramFigure 4

*Women are considered eligible if their household income is at or below 200% of the federal poverty level, they are younger than 45, and are not pregnant or trying to become pregnant. We did not have information about eligibility based on citizenship and qualified immigrant status.

Conclusions and Policy Implications

After multiple changes to Texas’ family planning programs over the last several years, women’s access to care varies considerably by their insurance status. More than half of uninsured and publicly insured women are not using the type of contraception they would like to be using, in particular IUDs, implants and permanent methods. These findings, together with women’s reported barriers accessing care, suggest that low-income women in Texas experience challenges finding family planning providers to obtain the services they need.

To decrease the percentage of low-income women who have no coverage for women’s health services, the Health and Human Services Commission (HHSC) should expand outreach to raise awareness about the HTW program. These approaches should make a concerted effort to reach women who have not had children. Moreover, the citizenship and residency requirements should be removed. Additionally, HHSC and county health districts should develop and improve strategies that facilitate women’s ability to identify family planning providers and ensure those providers are accessible and have the capacity to offer the full range of contraceptive methods and other services women want and need. These efforts will help the state achieve its goal of supporting the health and well-being of all Texas women.


We conducted a statewide representative survey of Texas-resident women between ages 18 and 49, who were part of the Ipsos KnowledgePanel. Between February and March 2019, 785 women completed an online survey that assessed their contraceptive use and access to family planning services. For this brief, we limited our sample to 572 women between the ages of 18 and 44 who were not pregnant or trying to get pregnant (Table).

Table: Survey Respondents' Characteristics

Table 1

  *Numbers may not sum to 100 due to rounding.



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