Update: Bobby Jindal announced Tuesday evening that he is dropping out of the race for president.
The Planned Parenthood Health Center in New Orleans can be found inside a modest house in the uptown neighborhood of Louisiana's largest city. If you didn't see the sign out front, it would be easy to mistake the small building for one of the shotgun-style residences lining the street. Still, thousands of people rely on the clinic for reproductive health-care services ranging from sexually transmitted disease and cervical cancer screenings to treatment of urinary tract infections. The clinic does not perform abortions, nor does its sister facility in Baton Rouge.
Together, the facilities serve about 5,200 low-income Medicaid patients, but this didn't stop Gov. Bobby Jindal from cutting off Planned Parenthood from its Medicaid contract with the state in August, citing the now-infamous undercover fetal tissue research videos that have since been repeatedly debunked. Jindal was in campaign mode: He had announced his campaign for presidency a month earlier.
Planned Parenthood filed suit, and in October, a federal judge ordered the Jindal administration to reinstate Medicaid payments to the nonprofit medical care provider, effectively allowing Medicaid recipients who rely on Planned Parenthood to continue seeing the provider they prefer while Jindal spends taxpayer dollars fighting the case in a federal appeals court.
The Planned Parenthood cutoff was part of a larger pattern for Jindal. His administration had already refused to set up a health insurance marketplace and blocked Medicaid from expanding in Louisiana under the Affordable Care Act. Jindal routinely plugs his opposition to the ACA and his fight with Planned Parenthood on the campaign trail.
One thing you won't hear Jindal bragging about on Fox News: Louisiana reports more gonorrhea infections than any other state in the nation, according to the Centers for Disease Control and Prevention. In 2013, Louisiana ranked third in syphilis infections and second in chlamydia infections out of all 50 states. Jindal's state also has some of the country's highest rates of HIV and AIDS cases, as well as unintended pregnancies.
Jindal can't blame these numbers on "loose morals" or Bourbon Street. Louisiana also has high rates of poverty and unemployment, and low-income people, particularly rural women and women of color, are chronically underserved by the state's public reproductive health-care system.
There are about 130 publicly funded health clinics in Louisiana, but in 2013, they provided contraceptive care to only 14 percent of the 325,000 Louisiana women in need of publicly supported contraceptive services, according to the Guttmacher Institute, a reproductive health think tank. About half of these women are Black or Latina. About 113,000 live below the federal poverty line, and 102,000 are uninsured.
Nearly 30 percent of women in need of contraceptive services in the New Orleans area found them at the Planned Parenthood center that Jindal is fighting to defund.
"Our need is so great that even with all of these clinics providing services, we are not making a huge dent in the amount of people who need to be seen," said Taslim van Hattum, director of maternal, child and family health at the Louisiana Public Health Institute (LPHI).
Van Hattum said cost is a major factor, and 55 percent of uninsured women in the state report facing an obstacle when seeking any kind of health care, compared to 25 percent of insured women. Women make up more than half of the 260,000 Louisianans who remain uninsured, left without an affordable option because the Jindal administration refused to expand Medicaid, according to the Women's Law Center. Nationally, women make up the majority of uninsured people in states that failed to expand Medicaid.
Van Hattum said the lack availability and accessibility of services - especially for rural women - could also prevent or delay people from finding care at public clinics. Add to that the general social stigma around sexual health issues, which is exacerbated by the pervasive inaccessibility of care.
"Unfortunately, there are already preexisting stigmas, but a delay in care makes a condition more chronic and more stigmatizing, and manifests serious problems in women's health," van Hattum said.
High HIV Rates and Low Rates of Care
Sexual health care is not just about family planning. Medicaid is the largest provider of HIV care in the United States, and LPHI estimates that Medicaid expansion would also benefit 4,000 people living with HIV in Louisiana. Many people living with HIV are not eligible for traditional Medicaid unless they develop AIDS and become "categorically disabled," but the ACA's Medicaid expansion eliminates that requirement.
Current HIV treatments can effectively suppress the virus, especially if treatment begins early on, allowing patients to live longer lives while reducing the risk of transmitting HIV to others. In Louisiana, however, 30 percent of the estimated 18,000 individuals living with HIV are not receiving HIV care, according to LPHI. Advocates say this treatment gap makes expanding Medicaid critical, in a state that had the nation's third-highest rate of new HIV infections in 2013.
"Our program's goal is to get folks in care if they are living with HIV so they are retained in care and achieve viral suppression," said Russell Brewer, who directs LPHI's HIV programs and organizes the Louisiana Community AIDS Partnership. "If they do, it's not just better health outcomes for them; it's better for the community as a whole and the state as the whole because, if a person is HIV-suppressed, then they are less likely to spread [the virus] to other people."
Cleaning Up Louisiana's Health-Care Mess
In addition to supporting individuals in getting the care they need, insuring more people under Medicaid expansion would also inject $15 billion in federal funding into community health-care providers and the state hospital system, which is facing budget shortfalls due to what The Advocate newspaper in Baton Rouge calls the "big Medicaid, healthcare mess" left by the outgoing Jindal administration.
Planned Parenthood, health department clinics or other nonprofit health centers that are primarily funded by the federal government currently provide for the majority of women seeking public reproductive care in Louisiana. Van Hattum said the extra Medicaid funding would help expand services beyond women's health centers and specialty clinics, making it easier for people to access services in one place.
"What is so exciting about ACA and Medicaid expansion is it gives us the opportunity to shift women's health and reproductive health into primary care service, when traditionally they have been siloed [at separate facilities]," van Hattum said.
Jindal's decision to block the Medicaid expansion may have provided him with cannon fodder in the Republican presidential debates for candidates polling too low for prime time, but it's become increasingly unpopular in Louisiana. Even Sen. David Vitter, the hard-line Republican running an embattled campaign for governor, has said he would consider expanding Medicaid if elected to replace Jindal, although with some restrictions. Vitter's opponent, Democrat John Bel Edwards, has said expanding Medicaid rolls is "a matter of moral responsibility."
It's unclear how Jindal's legal fight to defund Planned Parenthood will fare if the appeals court doesn't throw it out before his term ends in January. The US Justice Department has already warned Jindal, along with officials in Arkansas and Texas who are attempting to strip Planned Parenthood's Medicaid funding, that his efforts may violate federal law, and a federal judge blocked a similar effort in Alabama in October.
It's also unclear if Jindal's attacks on Planned Parenthood and Medicaid are helping him in his quest for the presidency as polls consistently show his support among primary voters hovering around or below 1 percent.