 Okay, let's go ahead and get started. Again, welcome. My name is Dr. Jan Rialini. I'm the chair of the Texas Women's Health Care Coalition, and I also serve as president of Healthy Futures of Texas, which is the nonprofit organization in San Antonio that serves as the fiscal agent and leader for the Texas Women's Health Care Coalition. And we're delighted to have such a wonderful turnout today. I have lots of things that I could say, and I wanna make sure that we talk about things that are helpful to y'all. Let me ask, how many here are staff legislators? Okay. Good, how many here are staff and something related to the legislative session? Okay, so we have some additional. And how many are members of the Texas Women's Health Care Coalition from those organizations? Good, so we have a good turnout there. And who did I miss in that process? Who else is here? Okay, good. How many folks have staffed legislative sessions before? Okay, for how many people is this your first time around? Okay, so I'll try to kind of balance some things that maybe some of you have heard before. So the folks who are new to the issues can help follow along. And please, please, this is intended to be interactive. So I could be heard. I'm standing behind this podium, but I really want to reach out to you to ask questions or make comments as we go. And if there's things that you wanna know more about or less about as we go along, please let me know. First, let me take the opportunity to say thank you to Representative Donna Howard and her Chief of Staff, Scott Daigle, who I think is still here. Thank you. Thank you so much for helping us arrange to be able to use this room and to be able to talk with you today so close to your offices. We can't tell you how much we appreciate you. Thank you so much. And I wanna say thank you to all of our coalition members who are in the room. Thank you for your support and know that although I happen to be the individual talking, it's the coalition members that make this work, that really give it the power to help people understand what is needed for women in Texas. So thank you so much. Thank you to all of you who are here. Okay, well, next slide, please. There we go. So the Texas Women's Healthcare Coalition, what is that? It's a group of organizations. We now number 46, but we're increasing all the time. Some of us are physician organizations, nurses or nurse practitioner organizations, healthcare organizations, providers. We have many advocacy organizations and we have faith organizations who are involved with us as well. And we're all focused on prevention. Please, next slide. This coalition was formed in 2012 as a response to the big cuts, the severe cuts that happened to the family planning program, the DSHS, Department of State Health Services family planning program that occurred in 2011. And we are gaining members and gaining understanding from many in the legislature on both in the house and in the Senate and in the agencies about the importance of preventive care, how it is really different from abortion and how we need to support that for healthy women, healthy babies and healthy families in our state. It also helps us save money. So the first on this figure, you see what we tried to do at the end of the last session in 2013 was give sort of a visual picture of what happened over time with funding for that preventive care for women. And if you see the pipe is about this big in 2010 before the cuts was cut basically two thirds in that session in 2011. And then in 2013, when you patched together all the different programs, including one that's outside of the state government, you see that we're funding wise, theoretically we should be able to reach as many women as we could before those cuts happened. There were many people who were very important to that process of encouraging support for the restoration of funding, getting that funding for expanded primary healthcare, for family planning, many, many people. I think the coalition was helpful also. But there were some folks, Senator Jane Nelson in particular in the Senate was extremely important here on the House side. We're very grateful for Representative Sarah Davis and Representative Howard, Representative Dukes and Representative Zerwas for all the help. And of course, there are many others, representatives and senators alike who were involved and we're very grateful for their efforts. So no problem, right? We can all go home now, the funding is there. And that was sort of a surprise to me. I thought this would be a shorter term project. We, you know, fix it and then we can all go home and relax. But it turns out there's still a lot of work to do. And on the next slide, you see, I tried to put together a slide that shows you what the need is in Texas for the services that we're talking about, the prevention services for women and what the supply is estimated to be from the different funding streams that we have. So if, and we're not even considering the 18 and 19 year olds here, we're just considering the 20 to 44 because the Guttmacher Institute divides it up that way. Not sure why, but these are adult women. Over 1.3 million adult women are in need of the services, not just the services, but also in need of public support for the services. So there's a much higher number of women who need the services. And these are the ones who need publicly subsidized services, 1.3 million and above. And that estimate is for 2012, a couple of years ago. The estimates for what we have now, about 129,000 women were seen through the Title X Network with the Women's Health and Family Planning Association of Texas over the last year. So that's the best number we have for that. And then if you add up all the estimates from the recent letter from the HHSC, the numbers that they estimate for 2014, you get about 267,000 that family planning patients that would be seen through the DSHS, Texas Women's Health Program. And the DSHS is both Family Planning and EPHC. Next, we'll explain all those terms shortly. So let's back up and what kind of stuff are we talking about here? What is this stuff? The services are basically the prevention stuff that helps women stay well and prepare for a healthy pregnancy, time a pregnancy if they want one and avoid a pregnancy if they want one, if they don't want one. It's not abortion. Matter of fact, by statute that has never been the case that any of these funds were used for abortion and abortion is certainly excluded. So our group doesn't focus on that. We're not looking at that issue. We're not looking at the issue of any particular provider. What we're looking at is getting the services that women need to help them stay healthy, to have healthy babies and to reduce the cost to the state. So here's what the services are. It's much more than family planning. It's screenings for breast and cervical cancer. Some ages that includes breast exam and pap smear, high blood pressure screening, diabetes, cholesterol, obesity, mental health issues like depression, one of the most common abuse and violence issues which are also very common, especially in low income women, but among women of all stripes and screening for sexually transmitted infections. Matter of fact, one of the ways that the government grades physicians as to how well we're doing is whether we get a yearly test for chlamydia on women that are 25 and under. So that's an important measure of quality that is recommended for all young women who are sexually active to have. In addition, it includes contraceptive counseling and helping them understand what is available, what their options are, if they're planning a pregnancy, how to address some of those issues so that they will be healthy, be taking their folic acid and be as healthy as possible for the pregnancy. It also covers the different methods, the supplies, the actual medications or devices, and it covers followup. In the expanded primary care program that is the new program that was instituted last year, there are some additional services as well. Prenatal services, both medical and dental. Use of case management through community health workers is encouraged. And diagnosis and treatment of a number of different conditions as well as mammograms. Usually those are for older women, older than 40. Questions about the services? Is anything missing there? Anything you think shouldn't be there? Yes. Post-delivery longing, long-acting contraceptive advice, is that not included in your interest, is that right? So the question is whether we do deliveries and whether postpartum contraception is part of what we look at. And the answer to that is some of our members do deliveries and others don't. Some are providers and some are not. The coalition as an entity doesn't do any medical care. But the postpartum issues are part of what we look at in our state legislative agenda. In particular, we are looking at the sunset recommendation for an automatic enrollment after a Medicaid delivery or an emergency Medicaid delivery, a trip delivery, so that that woman can have a seamless entry into a continuation of her access to birth control. And then some of our members are also working on the issue of getting Medicaid to pay for the devices in the hospital as a separate code. So that's going on as well with some of our members. The coalition as a whole is not addressing that with some of our members are. Other questions, yes? I just wanted to tell you more about what a screening is and then if someone has a positive screening, where do you refer them? So the question is, what is a screening on some of these things? And what do you do if you have a positive screen? Great question. The screenings are recommended at different ages for different populations for a number of these things. For example, a pap smear is not recommended until a woman is at least 21 years old. And then how often is less often than yearly now is recommended. So if you take that and blood pressure screening is recommended for basically every adult when you see them in the office at least once a year. Diabetes screening and cholesterol screening is a little bit more specific for populations more at risk and women are less at risk than men. So instituting cholesterol screening would take, you know, be with older women rather than with younger. So what do you do if you have a positive? Someone turns up to have diabetes or high blood pressure or an abnormal pap smear dysplasia or something that really looks like it might be even cancer. What do you do with that? Well, it depends on the system in which they're seen. The payment for that diagnosis and treatment may be available from special programs like the breast and cervical cancer program, cancer control program in Texas. For some women and some problems you may need to be referring them if they don't have insurance to county hospitals and clinics, federally qualified health centers and that sort of thing. For those of us who have worked at health department clinics where most people are uninsured that's something that we're used to doing. For people in private practice it's a little bit more hair-raising because people in private practice may feel like they as a practice need to take care of that. So that's one of the things that's made it hard for some physicians to participate in the Texas Women's Health Program. Did that answer your question? So, and then the other thing to say is that for a lot of women this is the care that they get. This is their entry into the health system. So whether they're seeing somebody at a federally qualified health center, what I call a little podunk family planning clinic out there on the planes, whether it's a federally qualified health center, their family doctor, their OB-GYN or whoever is involved, that it's a whole patchwork of providers that you see together doing this. And it's often the only care that women get in the year. So those are the services and the next, it's much more than family planning but next slide starts to tell you why these services are so important. And contraception in particular is, our goal is to make sure that all Texas women have access to preventive care that includes contraception if they want contraception. And this is why contraception is mentioned specifically in our mission because it means healthier babies. Planned pregnancies are healthier than unplanned pregnancies and unplanned pregnancies are very common in the United States, very common in Texas. We'll talk a little bit more about how common. But here's the big news is that you have with better birth spacing, you have a much lower risk of low birth weight, two thirds less, and that means children are less likely to have a whole range of issues in terms of their health, okay? So that's a really, really big one. And if you look at the concerns of health plans and the costs, Medicaid costs, this is really a big one of when kids are born too small, born too soon, that's when the costs really soar. And of course it's really hard on the babies and the families too. Preterm birth and low birth weight, infant mortality is lower among planned children born of planned pregnancies. And that means more of them will make it to their first birthday. There's fewer congenital abnormalities because diabetes can get under control because exposure to toxins can be addressed before someone gets pregnant, less exposure to tobacco, alcohol, and other drugs. And those women who have a planned pregnancy are much more likely to breastfeed, which has a whole bunch of, sorry, a whole bunch of things that help children be healthy as they grow. Healthier mothers is also an outcome with access to contraception, less postpartum depression after a planned pregnancy than after an unplanned pregnancy. And half that incidence. Women who have planned pregnancies are more likely to be physically active. They're less likely to be overweight or obese, and they're more likely to take their vitamins, their folic acid, and more likely to have much less stress, which is really important in terms of family dynamics and so forth. If we look at the other services, the screening and treatment of other things, besides the contraception issues, you see that there's a big effect on women's health there as well. Early detection of diabetes, high blood pressure, the other problems that we talked about can make a huge difference. The breast and cervical cancers in particular, very important to catch early, be able to treat them when a cure is more likely. There's better birth spacing with the regular checkups, and entry into healthcare is really important for women to have a medical home, just like for everybody to have a medical home, where if you have a problem, you know where to start. Next please. Planned pregnancies also have a big effect on children in general, from a social and economic standpoint. Children just fare better, less likely to live in poverty, and they're gonna have fewer behavioral problems if they come from a planned pregnancy than an unplanned pregnancy. The parent-child relationships are better. There's lower incidents of this distant relationship with both moms and dads, and there's a higher chance of, for a planned child to be living in a two-parent household for the parents to be married and for those parents to stay together. So those are all things that help children grow up with the kind of support and resources they need to really thrive. Planning pregnancy also has benefits for the parents in the family well-being department. Less relationship conflict. How many of you have ever had relationship conflict? Really? Okay, so you're gonna give the talk on how to avoid relationship stress, right? How to avoid relationships we have over here, okay. But this is really an important piece of the puzzle in terms of forming stable relationships, and what we see so many times with unmarried 20-somethings is that they have an accidental pregnancy, and then they have this crisis that may or may not mean that the couple tries to stay together, but having that relationship worked out beforehand is much healthier, it's much more successful in terms of economic outcomes. So planning is important with that. They're less likely to have depression and postpartum depression. There's greater attachment to their children, and that feels good, I can tell you from firsthand. The child development is gonna be more positive, fewer problems, and the relationships overall are gonna be better between parents and kids. So all that health and social stuff is good, better among planned pregnancies than unplanned pregnancies. And what do we mean by unplanned pregnancy? Anybody? Okay, who decides if it's planned or unplanned? The woman, right, not me, but the woman herself classifies that pregnancy as was she trying to get pregnant at that time or not. Sometimes it's just mistimed, other times it's totally unwanted, like she never wanted to get pregnant, and those are the ones that are particularly high risk. But the other reason, especially to talk to legislative folks is about the cost of unplanned pregnancy, because among the Medicaid population, the nearly 60% of our, well, 55, 54% of our births statewide are Medicaid births, right? So the state and the federal government pay for that together. And that's a lot of births, and it turns out that 57%, almost six in 10 of the births are results of unplanned pregnancies. So most of those are gonna turn out very well, and the babies will be cherished and wanted and loved when they arrived. But their risks, as we've seen, are gonna be much higher. For the baby and for the mom, more often need the NICU and so forth. So this costs the state an incredible amount of money. Texas is second only to California because of California's high number of people to the cost of unplanned pregnancy and delivery, and it's over $1.34 billion a year. That's huge. Those are pregnancies that have high risks and high costs for the state. Now once people are in the system and are delivering and caring for their children, we want to support them. We don't want to put them off in a corner because a pregnancy is unplanned. It doesn't work that way. It's generally a very positive experience to have even an unplanned child. On the other hand, those unplanned children are at much higher risk. So next, part of what we're here to say is that the dollars spent on contraception and providing that contraceptive care that's a basis of this preventive care, the reason why women come in many times as a matter of fact is that you get a huge return on investment. For every dollar spent on contraception and contraceptive care, the return is near $6. So six for one is pretty good. There's a new study that says a little bit over $7, but I have to look at that a little closer before I put that in the slide. It's at least about $6, so that's really good. Okay, so what is the, we have an issue that is important that unplanned pregnancy makes a difference in terms of money, in terms of health and social issues and come to find out it's really common, okay? So it's important and it's common. 52% of our pregnancies in Texas are unplanned, 52%. Nationwide, it's only 51%, something like that. That amounts to over 300,000 pregnancies every year. And that number, that 300,000 is several years old, so it's probably higher now. The other thing about unplanned pregnancy is that it's what we call a health disparity. So health disparity is when you have a health issue that is different for one group of people than it is for another group of people. And most commonly you're talking about minorities or people who are at low income poverty levels. And that's exactly what we see with the issue of unplanned pregnancy. It's much more common and increasing actually among women who are low income. On this slide you can see that the poorer women as you go over time have increasing percentages of unplanned births, unplanned pregnancies, where the more affluent women with access who have insurance and have access to the newer forms of contraception, which are so effective, their rates are going down. There are 1990, 1994. So we have someone asking, why was there a dip in 1994? Any thoughts about that? What was going on in 1994? Welfare reform. 97 is when the welfare reform went into effect. It was signed in 96 and went into effect in 97. I don't know. Interesting. But we want to go that direction again. Okay. Okay, so it's important and it's common and turns out it's really preventable. Close to 100% preventable as a matter of fact. And we now have a couple of studies that show us that access to the long acting reversible contraceptives, the higher effective, more effective contraceptives can really have an effect on that rate of unplanned pregnancy as well as the rate of abortion can really lower it. The contraceptive choice project in St. Louis has shown us that if you get rid of the information barriers like women know about it, they know that it's an option for them. They get to ask questions and they are able to learn about it. And if you get rid of the cost barrier, that it doesn't cost them anything, the $1,000 or a little bit less that it often costs someone to pay for the initial device, the IUD or the implant. If you get rid of the cost to the patient, then many more women will choose these. So we have some, it was about 10,000 women, over 9,000 women participated in the study and three out of four of the women chose a long acting reversible contraceptive with those barriers removed. So and it dramatically reduced unplanned pregnancy and abortion. So we have a handout about LARCS, the long acting reversible contraception. So our shorthand is to do this, this is no, a bird. And for women themselves, that long acting reversible contraception doesn't make that much sense. It doesn't really sing, you know. What really seems to communicate well to women is that these are low maintenance options. In other words, this is where the default is you don't get pregnant rather than the default, like if you don't do something that you will get pregnant. It really changes that up. So it's low maintenance and it really lasts for several years. Some of them are three years with the implant is three years, next planon. And then there's a new Skyla, which is a medicated levonorgestal IUD that lasts three years. It's a little smaller than the marina. Marina is the most popular and that's the one that has levonorgestal and lasts for five years. And then the paragard, which has copper, lasts for, well, it's labeled for 10 years, but we have a good data that allow us to recommend 12 years or even longer. So, and these are things that are as effective as having your tubes tied or having his tubes tied. Which is actually, that's actually the most effective thing on the chart. So think about it. But that's not part of our advocacy. That's just a side note. I noticed that the men in the room are not laughing. No, I think it takes a couple working together to understand their best options. And many times a vasectomy is one that men want. And in Texas, I think we could do a lot to make vasectomy more available for those men who want it as well. Did you have a question? Cost? The cost of the different bars that you can place. Okay, we will. These cost a little bit more than birth control pills, but they have one 20th the failure rate. So birth control pills have 20 times the failure rate of these methods. So the effectiveness and then the cost effectiveness over time, if you're looking at 12 years, then that means the cost is spread out over that time. So it depends how you look at it. But there's an initial cost for the device itself to be paid for. And that is something that needs to be addressed in whatever program that you have. So paying for that device, up to $1,000. Okay, next. Okay, so how do LARCs work? We have a handout on LARCs. It's the one with the four squares on it. And this is sometimes controversial, especially with the hobby lobby decision being in the news. A lot of people have focused on this lately, at least on the IUD. But here's what we know from science, is that the long-acting reversible contraceptives work primarily through inhibiting the fertilization, from preventing fertilization of the egg by the sperm before it happens, okay? The implant next planon that goes in the arm, down here, is works by preventing the ovary from releasing the egg. Okay, so it's very reliable in that sense. That's why it has such a low failure rate. It also has other effects, but its effectiveness is agreed upon by experts to be from restricting that ovulation. IUDs, we have two kinds of IUDs. The one with copper and the one with levonardestral, which is a progesterone-like medication. And the progesterone, the medicated ones, they work by, we believe, primarily by preventing fertilization by affecting sperm. Now, I think the common thought about sperm is that they are able to go and swim and find what they need to find and fertilize what they need to fertilize. And we often don't realize how much the women's reproductive tract makes a difference for the function of sperm. They have to be capacitated in glands in the cervix. They need to be able to swim properly and function properly after that to get through the uterus and up into the tubes. And all of that is changed by both of these types of IUDs, by the copper and by the moraine and skyline, the levonardestral. We know that these IUDs could also interfere with implantation. So for some people, that's kind of a deal breaker. If it might work after the joining of the sperm and the egg, that might be a deal breaker for them. But for most women and most people, the low chance that that's actually happening is something that they're comfortable with. Questions about the mechanism of action. Comments about the mechanism of action. Do we need more dessert to think about that? So how many of you consider how IUDs work to be controversial for yourselves, for your world? Oh, that's not a fair question. So the people who laughed thought it might be controversial. But some people do. I think it depends on your point of view. From a medical perspective, I'm very comfortable that almost all the time these work to prevent fertilization. I can't prove that it never ever works after fertilization, but I'm comfortable that it usually works almost always before. Somebody was gonna ask, yes? What are the medical long term effects of a woman not dropping an egg every month or not having her cervix replenish the lining? Like that's always my question about large. I just want a question. If a woman doesn't have cycles, is that bad? If a woman doesn't release an egg every month, is that bad? That's what happens when you're on birth control. Does it crowd? Not that we know of, not that we know of. It's important to put it in perspective that women, before we had any manipulation of the cycle, usually didn't have monthly bleeding. Usually they were either breastfeeding or pregnant. And so there wasn't that much ovarian turnover as we have in the modern world. And with birth control pills, we've had a lot of study that shows that not bleeding, not ovulating for long periods of time is not dangerous. In fact, it protects you from two kinds of cancer. Anybody know? Ovarian cancer protects women from ovarian cancer and it protects women from endometrial cancer. So that's birth control pills. Okay, not these. Yes. Okay, so the question is it, right. So if you're not having the usual cycle hormone changes, what about those effects? And those again have been studied, especially with birth control pills, but with all these methods, women are being studied over long periods of time and these are exceedingly safe. Next please. So this is a graphic to help you see the comparison of the pregnancy rate for women who use birth control pills or patches or rings, which are the green bars versus the women using the long acting reversible contraceptives in this big 10,000 women study. And you can see that there's a big difference between larks and the shot and birth control pills. And this was the really dramatic thing to see how it worked in practice when you got rid of the barriers. And this has now really opened up the field to really make much more progress from that slide that we saw from 1994 and all, and then going up. So this is where the excitement is in the field to be able to make these available and make a lot of progress. Horsed and uninformed sterilizations of four women primarily with color. I think I saw someone just recently, they're still with it somewhere. And so we've been running the drafts on some of this stuff with these rights organizations to make sure that there are more than particularly getting Medicaid reimbursement for the larks and then getting to the longest known hospital. So they're gonna need this portion. Thank you for your question. He's asking about the history of forced sterilization many times of minority and poor women in the past. Part of these programs that is so important is the voluntary nature of it. The whole idea is not to be convincing women to use anything, but rather making things available for what they would like to have. And that's super important. I'd be interested in talking with you about who you think we should talk to about this because we want that to be very clear. We're not pushing contraception, we're pushing access. Can you understand that? There are gonna be some people who don't and this is awfully close to that really ugly thing. So I think that's pretty important. Thanks for your comment. Just in response to that, my name's Al and I work at the National Latina Institute for Reproductive Health and the Latina women that we've worked with in the Rio Grande Valley that we've surveyed and who would be disproportionately affected by some of these formal policies you're referencing actually prefer this form of contraception and the Texas Policy Evaluation Project actually has some good data on that and it's available on their website. I think it's a good question because there is a history there but I can tell you from my experience in the data that I'm familiar with that Latina is in Texas over one million women. So it's your organization that'll be getting a little, I just think maybe have some brass tops kind of saying, look, this is a good thing for the women that we represent. This is not that other thing. It's okay. Yeah, I think we come down to what Dr. Rialini just mentioned. We get nervous when people don't emphasize the voluntary nature of this and how different work-control needs should be available to all women, the option. So when we hear it framed in terms of options and choice and voluntary, we're comfortable and we'll say so. Right, thank you so much for that question and for the response on it. But I think this slide shows you that for women who are going, asking in a clinical setting for birth control of some sort, for contraception, access to these more effective ones is very important for women poor or rich. Next please. So just to summarize, the evidence is strong. They're highly effective and safe and they're safe for most women. You don't have to have had a child already, for example. And the American College of Obigens has really laid that out, that these should be available for more women. Next please. So let's talk a little bit about the state programs and what's going on with those. We have two programs that provide these services, that fund these services in the Department of State Health Services which is the agency, you can think of that as the public health agency. And we have one program that's housed at the HHSC which is really the Medicaid agency. You can simplify thinking of those. There's a lot more complexity but it helps us think about that. And these agencies now are being proposed by the Sunset staff to be consolidated all into one agency. So we have these three funding streams, family planning, that's the stream that got cut so much in 2011, expanded primary health care program which is about 60% family planning and 40% other kinds of services for women. And then the Texas Women's Health Program which began in 2013 after the federal funding piece of it was excluded. Okay, next. And the sunset process which I assume you all are at least a little bit familiar with at this point since that's what's going on right now with the recent hearing. The staff recommendation was to consolidate these three funding streams. And on the next slide you see a little comparison of what each of these, the Texas Women's Health Program, family planning program, expanded primary health care and then what the sunset proposal is to kind of compare and contrast. And you can see that the plan proposed, the program proposed would be a simplified program. It would be fee for service only kind of like the Texas Women's Health Program is right now. There are certain things it'll pay for and you do the service and you get paid. That's what fee for service is. It would cover women up to 185% of the federal poverty level. Women ages 15 to 44 and they would need to be Texas residents. And then in addition to the services that we listed that are available through all these different programs, the basic family planning and screening program, it would, if you come in as a family planning patient would be covering a good deal of diagnosis and treatment of the conditions that might be found at that time. There's also a provision for mammograms, treatment of any cervical dysplasia and some case management as well. So this is the combination that was proposed. We recently testified at the hearing and our testimony is available as a handout in the back that we have some concerns. We're not opposed to consolidation per se but the plan as proposed needs some adjustment if it's gonna be successful and not lose providers, not put providers out of this business and not reduce access for patients on that basis. So a couple of, they're kind of technical but if you have only fee for service, then a lot of these providers don't have other funding to keep their doors open while they're waiting for that fee payment to come in. In other words, they couldn't go ahead and treat the patient. They wouldn't know if she was eligible and they would be at their own financial risk. So they need some form of grant or cost reimbursement as the DSHS programs do now, up to 50% some of the providers say. So that they can keep their doors open so they can continue to help with the eligibility process and so they don't have to tell women, okay, go on the internet and get your form filled out and when you get your card, come back. Which often maybe six weeks, something like that and they may come back pregnant when they wanted to avoid that pregnancy. They may come back sick with something that they had that could have been treated earlier. So that cost reimbursement is needed for many, many of the safety net providers. We're also concerned about that presumptive eligibility being able to take care of someone with a good faith effort to determine their eligibility and the staff time that you put into that so that you're not at financial risk as a provider. We want meaningful provider input into the process and perhaps an ad hoc committee that's temporary that would not continue after the process was completed but the providers need to be able to tell the decision makers what the consequences, the unintended consequences of their plan and how it's working would be. So that's something we feel is important. We would like to see a broader range of women served up to 250% of the federal poverty level as with the family planning program. That there would be no age restriction. For example, someone who's 45 and still needs birth control could get services through this plan and we'd like to have men still have access about 10% of the patients or five to 10% depending on the clinic who are seen in family planning are men and that includes STD checks and condoms and vasectomies. So we'd like to include that. I don't know what we'll do about our name was the Texas Women's Healthcare Coalition and some men too, yes. So the question is about the response to the comments that were made at the Sunset staff. The staff responded that men would have access to the primary healthcare program and that's how they could get taken care of. I think it's best viewed as well men have access to that now and it's not the expanded primary healthcare program we're talking about here, it's the original primary healthcare program which is pretty small and doesn't reach very far. And so that's why so many men have taken advantage of the family planning program through clinics that have been in tune to helping women's partners and men in the community who would like to address their sexual health and their childbearing. So it's just not very, yes it's there but it's there now and it's still needed now. So we'd like to serve more patients. We'd also like to maximize that benefit package and a lot of our members are fairly qualified health centers for example and physicians who see a broad array of things besides just family planning and so we'd like to have as much coverage as possible. I think that there's lots of different ways that Texas could consider what to do about how to maximize the federal contribution to healthcare in Texas, especially for low income people and poor people. But I think we also have to recognize that the more other services that we add besides family planning, we're gonna have to, if we don't wanna reduce the number of family planning patients, we have to increase the amount. So we've made a rough calculation that if the model were an EPHC model, expanded primary healthcare model, instead of a Texas Women's Health Program model. Everybody following me? If it was an EPHC model, that we'd need instead of 107.6 million a year, we need about 145 million a year to do that without reducing the number of women and family planning. And that's just a rough calculation. We're still missing some data with which to make an accurate calculation on that. So we wanna maximize the benefits package. Let's do as much as we can and for as many people as we can. And we really are interested in that last recommendation that wasn't for legislation, but rather to study that postpartum auto enrollment. And we really have been asking for that for a long time. So we'd like to see that expedited in whatever way is possible. As you can tell from our little trifold, which Ann is holding up here, there's one for you here. Our overall goals as a coalition are not just about the sunset, we're talking about the details of how our goals intersect with what the sunset is recommended. But we really want to increase funding for women's preventive healthcare. We'd like everybody to have healthcare, of course, but for this particular issue, we wanna increase funding. We wanna make sure that if there is consolidation that we're maximizing access and minimizing disruption. These are provider networks that have been recently in a great deal of turmoil once, twice, and now the third time, maybe the charm and kill some of them. So we wanna make sure that we're taking care of their needs. And we wanna increase provider capacity with reaching out to more providers, making providers more effective and making sure that LARCs are accessible both to the providers and to the patients that they're taking care of, getting rid of the information barriers and the cost barriers. Yes. So the question is what is the coalition's position on access to postpartum mental healthcare? We haven't taken an official position on that. We certainly would want to see those women in care that is able to detect those problems, but we haven't taken a position on how to take care of those problems once detected. Other questions? Yes. Do all of the healthcare programs, do they all cover LARCs? Do all cover LARCs and their removal? So the question is whether all three of the programs currently cover LARCs and their removal and yes they do, yes they do. I think that the DSHS and HHSC are already doing some things to remove barriers to those LARCs. And that's why you'll see the cost per woman per year has increased a little bit. So it's a short-term increase in the cost per woman because they're doing more LARCs. We don't really have the data on how much, but we have a little bit, but not as recently as we'd like to see. So there is a big push. I think Commissioner Janak is very much in support of access to LARCs. And again, nothing being pushed or required, but rather just to reduce the barriers so women can access the kind of care that they really would like to have. Well, I just want to say thank you again to all of you for coming. Thank you to Representative Howard and to all of your bosses for what they do. I know it's not an easy job. Thank you to Anna Chatillon. I want her to stand up so you can meet her. She's our staff at the coalition and she will be the person that you have to contact day and night during the session to ask any question and make any progress that we can. Thank you so much. Be sure and eat some of those little lemon squares for dessert because they rock. Thank you.