For an ambitious, aggressive disease like Zika, Texas is an ideal home. Earlier this week we learned that Zika—a nasty virus that has spread to over 25 countries—was transmitted by sex to a resident of Dallas. Six more cases of Zika have also been confirmed in Harris County, Texas. The appearance of Zika in Texas may be happenstance, but Texas’s health policies will make it easier for Zika to spread. Among other problems, Texas (1) fails to teach students about safe sex and reduces access to affordable, effective contraceptives; (2) has blocked access to Medicaid for up to 2 million low-income residents; and (3) is trying to restrict if not eliminate access to safe abortion. Not a bad place for a communicable disease that can spread through sex and cause birth defects.
1. Promoting abstinence-only education and reducing access to affordable contraceptives. Texas is a self-proclaimed “abstinence-first state.” More than 9 out of 10 Texas high-school students receive abstinence-only education; according to a survey discussed by Texas Monthly, “more than half of Texas students were losing their virginity in high school and a startling number weren’t using condoms.”
Abstinence-only education, in other words, doesn’t keep teens from having sex; instead, it leaves them less likely to have safe sex and more likely to get pregnant or contract an STD. Alas, these problems don’t vanish when Texans become adults: In the United States, Texas has the 13th-highest rate of syphillis, the 10th-highest rate of chlamydia, and the 3rd-highest rate of HIV.
Those who have learned about safe sex despite the state’s best efforts confront another problem: obtaining contraceptives that are both affordable and effective. For Texans without Affordable Care Act-compliant health insurance (see below), Title X-funded health clinics can be essential to receiving birth control. In 2013, however, Texas excluded Planned Parenthood from its program to fund family planning for low-income women. On Wednesday, the New England Journal of Medicine published a study concluding that after these cuts, fewer low-income women got birth control—especially effective, long-acting birth control like the IUD—and more low-income women got pregnant.
None of this inspires confidence in the state’s ability to prevent the transmission of Zika through sex and help infected women avoid pregnancy.
2. Blocking access to Medicaid. When it comes to communicable diseases (well, any diseases), prompt detection and treatment are key. That happens only when people can afford preventative care. Yet more than one in five Texans have no health insurance; Texas is the only state with an uninsured rate that high.
These coverage gaps are no accident. Although the Affordable Care Act contemplated that states would expand Medicaid to cover anyone with a family income as high as 138 percent, the Supreme Court’s decision in National Federation of Independent Business v. Sebelius made it much easier for states to refuse to do so. Texas is one of many states that refuses to expand Medicaid—even though the federal government would pay nearly the whole bill.
As a result, between 900,000 and 2 million low-income Texans lack access to otherwise available health coverage, including coverage for preventative care. For them, the diagnosis, treatment, and containment of Zika will have to wait for the emergency room.
3. Restricting access to safe abortion. Those who are infected with Zika and pregnant have another problem: Zika is linked to and may in fact cause microcephaly, which causes babies to be born with abnormally small heads and suffer brain damage. (As The Onion put it, “Zika virus joins lack of paid leave, unaffordable child care as reasons woman afraid of getting pregnant.”)
Many Zika victims live in countries that ban or curtail access to abortion, and the epidemic is renewing pushes to relax strict abortion restrictions in countries such as Brazil. But don’t expect a similar perestroika in Texas—unless it comes from an order of the U.S. Supreme Court. Over the past several years, Texas has enacted laws designed to close as many Texas abortion clinics as possible. The state has only 20 abortion clinics to serve over 5 million women, and access to safe abortion in Texas has already suffered. The problem may soon get worse: If Texas wins an upcoming abortion-rights case at the U.S. Supreme Court, its total number of clinics will drop to 10.
The resulting difficulties and delays in obtaining an abortion are especially difficult for women who are infected with Zika and learn that their fetus has microcephaly. A woman who wants to have an abortion after getting this news has to act quickly: Diagnosis of microcephaly typically doesn’t happen until near the end of the second trimester—usually at around 24 weeks—and abortion is legal only before the fetus becomes viable, usually at 24 to 28 weeks. Unfortunately, if the Supreme Court rules for Texas, approximately 17 percent of Texas women will need to travel at least 150 miles—each way—to reach a clinic. And they might have to make the trip more than once, because the state also requires women to have an ultrasound 24 hours before an abortion. So while time is of the essence for women with Zika, Texas is adding roadblocks.
The blurring of politics and public health makes it harder to contain epidemics. And public-health policy in Texas is uniquely ill-suited to stopping a disease like Zika.
Greg Lipper (@theglipper) is Senior Litigation Counsel at Americans United for Separation of Church and State.