Introduction

As of spring 2021, more than 2,500 anti-abortion centers, or AACs, (sometimes called “crisis pregnancy centers,” “CPCs,” or “pregnancy resource centers”) exist in the US. These AACs aim to deter people seeking abortions from receiving the medically accurate, non-judgmental healthcare they need. They operate with harmful and biased goals, often convincing and coercing individuals away from their abortion decisions by employing medically inaccurate and biased information. While most people have likely encountered an AAC in their communities before, they may not have been able to distinguish it from a holistic healthcare provider. Even more inconspicuous is the fact that many of these centers are funded by public dollars.

Many of these centers belong to deceptive and coercive AAC networks, which are larger AAC organizations. Some AAC networks have financial relationships with state agencies, such as state health departments, to administer AAC programs, commonly referred to as “Alternatives to Abortion” or “A2A” programs (see Terminology Box below). Between states, program names may differ slightly, as shown in the “A2A Programs in the US” map below.

To better understand how AAC networks and A2A programs operate and the harm that they cause, this report maps A2A programs across states and analyzes the patterns of these programs across state lines. The four major patterns explored in this report include the following:

• The increase in states using public dollars, both state and federal, to fund A2A programs;
• The misuse of those dollars by programs in state after state;
• The lack of oversight by states, which exacerbates that misuse; and
• The tactics shared by state legislatures to escalate and expand A2A program overreach.

Terminology Box

Background

Before diving into the aforementioned patterns of how AACs, AAC networks, and A2A programs operate, it is worth providing some background on their deceptive tactics. These AACs often deploy elaborate techniques aimed at bringing people through their doors instead of those of actual medical clinics that provide abortions. They are also careful to emulate the look and feel of abortion clinics through their centers’ names, webpages, and “services” offered. Overall, AACs want people to think they provide healthcare services such as abortion, yet they do not provide abortion or even refer people seeking abortion to actual medical clinics that do.

Also, AACs are also notorious for intrusively shaming people away from their personal abortion decisions. For example, a 2018 study found that a growing number of AACs have obtained licenses to conduct medically unnecessary ultrasounds intended to shame and dissuade people. As an additional scare tactic, many AACs promote medically inaccurate information, spouting exaggerated and downright false claims about the “risks” of abortion care. Examples include fearmongering that abortion is related to an increased risk of breast cancer and mental health conditions, even though these claims have been overwhelmingly disproven.

In addition to deceptive practices at AACs regarding appearance and information, as this report will chronicle, many of the AAC networks receiving state funds to operate A2A programs have track records of dubious financial practices. These instances of contract violations are not isolated to one state or one contractor. Rather, AAC networks have outsized influence and bring their faulty practices across state lines, often at the expense of state taxpayers. Further, A2A programs are often awarded no-bid contracts, meaning the contracts are written in ways that disqualify entities that are better-suited to provide actual health services than AAC networks and individual AACs. For example, the contract to administer Texas’ A2A program was offered in such a manner that only one AAC network could become the contractor, and conservative legislators publicly stated no other organizations’ contract bids would be considered.

Pattern 1: Public Dollars Funding Deception: A2A Programs Use of State Tax Revenue and Federal TANF Dollars

The aforementioned deceptive practices on the part of A2A programs are widespread across the US, and many are run using taxpayer dollars. At the start of 2021, 13 states had some form of existing A2A program infrastructure operated by a state agency and receiving state or federal funding: Florida, Georgia, Indiana, Louisiana, Michigan (defunded as of 2019), Minnesota, Missouri, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, and Texas. An additional three states introduced legislation attempting to establish A2A programs in 2021 (Arizona, Arkansas, and Iowa). The A2A program bills introduced in Arizona and Iowa failed, but the Arkansas bill passed, bringing the total number of states with A2A program infrastructure operated by a state agency to 14, and 13 with active contracts. To track the growing presence of A2A programs across states, the “A2A Programs in the US” map shown below categorizes the status of states’ A2A programs. The map indicates states that do not currently have A2A programs, states that attempted to pass bills establishing A2A programs in 2021, and states that already have A2A programs in place.

Made with Visme Infographic Maker

The information displayed on the “A2A Programs in the US” map is available via RewireNews and Facing South, both accessed April 6, 2021.

Using publicly available evidence, this report found that at least ten states have diverted or currently divert public Temporary Assistance to Needy Families (TANF) dollars away from families in need and into A2A programs. These TANF block grants are federally-funded dollars administered through state-run programs intended to directly support a state’s most vulnerable families. In fact, TANF dollars are supposed to give direct assistance to help struggling families with children pay for essential needs, including rent, food, and childcare. However, instead of actually helping people, TANF dollars, in many states, are used to pay for largely unmonitored and biased A2A programs. States in which TANF dollars have been diverted or currently are diverted to A2A programs include Indiana, Louisiana, Michigan, Missouri, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, and Texas. The specifics of these states’ TANF-funded A2A programs are profiled below.

Indiana

In 2014, Indiana spent $1 million in state funds on an A2A pilot program. In 2015, the Indiana State Department of Health increased the program’s budget, giving a total of $3.5 million in state funds to the AAC network Real Alternatives to administer its A2A program. Despite the fact that Real Alternatives is Pennsylvania-based, Indiana funneled its federal TANF program funds to Real Alternatives, siphoning public dollars away from Indiana families struggling to make ends meet. Even more egregiously, the state of Indiana awarded the contract amid the Pennsylvania Auditor General’s announcement of an audit of Real Alternatives’ contracts with the state of Pennsylvania. Similarly, TANF funds were also abused by Real Alternatives within Pennsylvania. In fact, as an investigative news outlet in Indiana reported, “The audit also discovered Real Alternatives was taking a three-percent fee from its service providers. Instead of giving providers the full amount of their reimbursements for services provided, Real Alternatives was taking some of that money from the Temporary Assistance to Needy Families Fund as part of the ‘fee.’” In the case of Indiana, the A2A program still relies on Real Alternatives, despite clear evidence of extremism and corruption.

Louisiana

Louisiana first began allocating state funds to an A2A program in 2003 to the tune of $1.5 million and has used TANF funds for its “Alternatives to Abortion Initiative” in the past, even as recently as 2019. This is especially concerning because Louisiana had the second highest poverty rate in the nation in 2020, with nearly one out of every three families with children living in poverty, a statistic that hasn’t improved since the inception of Louisiana’s A2A program, despite claims that the program supports families.

Michigan

In 2013, Real Alternatives was handed $700,000 to run a pilot program in Michigan and received a bump in funding in 2015. Later, in 2019, Michigan Governor Gretchen Whitmer rescinded Real Alternatives’ funding based on contract violations and Real Alternatives’ overall failure to deliver the services it claimed it would provide to people in Michigan under the A2A program. In 2019, the Michigan Department of Health and Human Services’ spokesperson admitted that Michigan’s A2A program was of “questionable benefit” and that a lack of oversight was a major impediment to even assessing the program’s effectiveness. This lack of oversight in Michigan’s former A2A contract with Real Alternatives, including the dubious use of TANF funds, is part of a broader pattern across state A2A programs.

Missouri

Since the $1.3 million dollar inception of Missouri’s A2A program in 2005, funding has increased to almost $6.4 million, with nearly $4.3 million in TANF funds and over $2 million in general revenue funds set aside for the A2A program in the upcoming budget cycle. Alliance for Life Missouri Inc., known as AFL Missouri, is handed contracts to run Missouri’s A2A program year after year, with TANF funds being drained from the state’s chronically underfunded services, such as emergency food assistance, that would actually help pregnant people and families. According to publicly available data, AFL Missouri is allowed to use Missouri’s public dollars to subcontract with 30 AACs. Under AFL Missouri’s contract with the state, it is tasked with the oversight of its own subcontractors, leaving little room for accountability to taxpayers in Missouri.

North Carolina

In 2013, North Carolina allocated a quarter of a million dollars to establish the Carolina Pregnancy Care Fellowship. In 2017, Texas-based Human Coalition, yet another out-of-state entity administering others states’ A2A programs, launched a pilot A2A program with North Carolina’s Department of Health and Human Services. Despite the fact that Human Coalition is not based in North Carolina, the state still managed to redirect over half a million dollars to AACs from federal maternal and child health grants originally intended to improve the health of low-income families in its own state.

North Dakota

In comparison to the size and reach of other states’ A2A programs, North Dakota’s “alternatives-to-abortion” program is small. Even so, SB 2391 managed to allot $100,000 “...from the federal TANF block grant funds...” just to “...inform the public about the alternatives-to-abortion program,” as is demonstrated in a 2009 legislative report for the state’s Health and Human Services Committee. Simply put, North Dakota’s A2A program directly gave an AAC — an entity with no expertise in marketing — $100,000 in TANF funds solely for marketing instead of using the funds to directly assist struggling families.

Ohio

Since its inception in 2013, Ohio has diverted TANF funds away from helping families in need and instead funneled dollars into its A2A program. While the use of TANF dollars to fund A2A programs is covert in many states, an anti-abortion group in Ohio, Ohio Right to Life, openly states it “pursued” TANF dollars in multiple budget cycles for Ohio’s A2A program. Alarmingly, Ohio passed $7.5 million for FY20 and FY21 for the program’s budget during the 2019 legislative session. In the previous budget cycle, just six AACs were the recipients of state program dollars. This begs the question, as one Democratic lawmaker expressed in 2019, “...what in the world is the state of Ohio paying $7.5 million for?” As seen in other states, Ohio’s A2A program is not held to a satisfactory standard of oversight, yet it consistently sees increased allocations of public funding year after year.

Oklahoma

Amid a 2017 budget deficit, anti-abortion lawmakers in Oklahoma intended to hand AACs nearly $1 million in taxpayer dollars under the ironically named anti-choice “Choosing Childbirth Act,” or HB 3676. Unsurprisingly, but still alarmingly, Oklahoma’s questionable A2A program got its start thanks to Texas’s dangerously far-reaching A2A program. During a hearing, the sponsor of Oklahoma’s bill revealed the legislation was based on a program “that has had great success in the state of Texas for a number of years,” according to investigative reporting from RewireNews. Incredibly, the Oklahoma State Department of Health’s “Alternatives-to-Abortion Services” 2016 annual report states that oversight of the A2A program only requires AACs’ services to be merely “outcome-based with positive results.” This lack of oversight allows dangerous territory for the A2A program to run amuck. This is especially concerning given that the A2A program regularly receives Oklahoma’s federal TANF funds amid chronic state budget deficits.

Pennsylvania

Using TANF funds for A2A programs is a practice that originated in Pennsylvania in 2001. More recently, in 2020, Pennsylvania still managed to take $1 million in TANF funds away from legitimate social insurance programs. Instead, Pennsylvania’s Department of Human Services gave the public dollars to its A2A program, despite its AAC contractor Real Alternatives’ deceptive track record, which is detailed in the section on Real Alternatives below.

Texas

Of the ten states funneling TANF funds to A2A programs, Texas is the largest offender. For example, since 2013, Texas has diverted $23 million in public funds to its A2A program. In FY20 and FY21, $6 million in TANF funds were diverted to AAC networks, including the Texas Pregnancy Care Network and Human Coalition. As a 2020 Texas Department of Health and Human Services’ report details, the Texas Pregnancy Care Network relied on 80 subcontractors to administer the A2A program, and Human Coalition dubiously operated two AACs in Texas. To demonstrate the outsized influence of AAC networks using state dollars, in FY21 alone, Human Coalition was given $8.3 million, and the Texas Pregnancy Care Network was handed a startling $34.7 million over two years. Through a no-bid process, the contracts were renewed, and these dubious A2A contractors were once again handed significant amounts of money, despite little contractual oversight and a history of failing to meet their stated programmatic objectives.

Pattern 2: Misuse of Public Funds

Because AAC networks actively coerce and deceive people seeking abortions, it’s no surprise that A2A programs and the contractors receiving state funds to run them use their outsized influence to harm all taxpayers. While the general public may believe their state tax dollars go toward initiatives that help people in their own communities and states, time and time again, Equity Forward has documented that this is clearly not the case. Major AAC networks, such as Real Alternatives and Human Coalition, are known to have troubling track records administering A2A programs.

Human Coalition’s Fraudulent Track Record

Mirroring the same patterns in other states, North Carolina’s pilot A2A program, largely run by Texas-based Human Coalition, was found to be wrought with the blatant misuse of public funds. For example, RewireNews revealed AACs within the Carolina Pregnancy Care Fellowship used federal funds to purchase $50,000 worth of religious propaganda over a period of five years — a direct violation of federal law. Disturbingly, the North Carolina Department of Health and Human Services, supposedly tasked with oversight of the program, failed to inform the state legislature of the malfeasance.

Despite Human Coalition’s troubling track record in North Carolina, conservative lawmakers in Arizona spent the past few years attempting to set up an A2A pilot program with Human Coalition at the helm. Since 2019 and again in both 2020 and 2021, conservative lawmakers and the far-right Arizona Center for Policy have attempted to conspire against Arizonans’ best interests by introducing legislation allowing Human Coalition, with its reprehensible track record, to run rampant with Arizonans’ tax dollars. Equity Forward’s forthcoming public records research will demonstrate the outsized influence of extremist groups on anti-abortion legislation in Arizona.

Real Alternatives Sending Money Out of State

According to its website, Pennsylvania-based Real Alternatives has spread its influence across 20 states by administering A2A programs in Pennsylvania, Indiana, and Michigan or consulting on additional states’ A2A programs. Real Alternatives revealed it has offered A2A consulting to AACs in the following states: Florida, Georgia, Iowa, Kansas, Louisiana, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Tennessee, Texas, and Wisconsin. An archived document created by Real Alternatives in 2016 shows it consulted in additional states beyond the states listed on its website timeline, including Alaska, Arizona, Nevada, and Oklahoma. Among states where TANF funds are diverted to AACs and A2A programs, this report found that Real Alternatives consulted with AACs in nine of ten states. This pattern is illustrated below. Despite Real Alternatives’ dubious track record, it still receives taxpayer dollars to run A2A programs in Indiana and Pennsylvania. This only further contributes to mounting evidence that A2A programs bring more harm than help to families across multiple states.

Information used in the A2A programs and TANF funds graphics are available via RewireNews, Facing South, Real Alternatives’ current website, and Real Alternatives’ 2016 archived report. All sources were accessed in April 2021.

Pattern 3: Lack of Oversight and Review

The misuse of public dollars outlined in each program named in Patterns 1 and 2 likely occurs because, despite being handed millions in taxpayer dollars, A2A contractors are subject to very little oversight or requirements to actually meet benchmarks or report on the use of dollars. In some states, such as North Dakota and Oklahoma, the closest provision to a reporting requirement is a statement that the program must be “outcome-based with positive results.” In Florida, the Department of Health’s already piecemeal oversight of its main A2A contractor, the Florida Pregnancy Care Network (FPCN), has been dramatically reduced in recent years. For example, in 2011, Florida required monthly self-reported reviews from FPCN’s executive director. Over time, reporting requirements diminished to annual oversight with loose guidelines. Later, in 2018, Florida removed a previous contract requirement stating FPCN’s subcontractors needed to be monitored every other year. Currently, the Florida Department of Health’s oversight of AACs involves vague “desk reviews,” without the clear evaluation standards, and lacks explicit timelines for completing those reviews. The abysmal lack of oversight of AAC networks stands in stark contrast to the strict oversight requirements imposed on abortion providers and entities providing abortion information and referrals.

As noted above, in FY21 alone, Human Coalition was given $8.3 million, and the Texas Pregnancy Care Network was handed a startling $34.7 million over two years. Through a no-bid process, the contracts were renewed, and these dubious A2A contractors were once again handed significant amounts of money, despite having little contractual oversight and a history of failing to meet their stated programmatic objectives.

As noted above, in 2019, the Michigan Department of Health and Human Services’ spokesperson admitted that Michigan’s A2A program was of “questionable benefit” and that a lack of oversight was a major impediment to even assessing the program’s effectiveness.

Pattern 4: New Wave of Carbon Copy A2A Legislation Brings Escalating Tactics of Intrusion and Invasion to States

In addition to blatant coordinated attempts to expand A2A programs in Arizona, Arkansas, and Iowa, anti-abortion lawmakers in a handful of states similarly attempted to pass legislation in 2021 that would track people who sought abortion care. Additionally, lawmakers in Arizona, Maine, and New Hampshire touted a new pattern of adoption fund legislation in hopes of further restricting abortion access.

As shown in gray on the above map, an additional three states (Arkansas, Arizona, and Iowa), attempted to pass legislation establishing basic infrastructure for harmful, misleading A2A programs during their respective 2021 legislative sessions. In both Arkansas and Iowa, conservative lawmakers introduced bills forcing people seeking abortion care to be subjected to biased information while also tracking anyone seeking abortion care via a state database. The provisions included in Arkansas’s and Iowa’s bills intrude upon peoples’ rights to make informed, private medical decisions.

Arkansas Funds Tracking of Patients and Privacy Invasion

In Arkansas, HB 1195, given the innocent title of the “Every Mom Matters Act,” or “EMMA,” was signed into law and established the basic structure of an A2A program. Beginning in January 2023, the state of Arkansas will spend between $4 million to $5 million dollars annually to contract with AACs to invade the privacy of people seeking abortion care.

HB 1195, signed into law and renamed Act 90, forces people considering abortion care to first be contacted by this A2A program to receive biased information via “resource access assistance offers.” Under the A2A program, organizations contracting with the state cannot “refer abortion providers, recommend abortion, or take any other action that directly or indirectly advises a woman to obtain or assists someone in obtaining an abortion.” Concerningly, Arkansas’s Act 90 also forces abortion providers to report patients to a state database and record “resource consultation IDs” in patients’ medical records so the A2A program can contact a patient prior to obtaining an abortion. The tracking aspect of Arkansas’s newly enacted law invades a patient’s right to privacy and links the patient to a state database, likely without patients’ informed consent or knowledge of the coercive, biased tactics deployed by AACs funded through the A2A program.

Iowa Takes Privacy Invasion a Step Further

Replicating the concerning pattern on display during Arkansas’s 2021 legislative session, Iowa took invading patients’ privacy under the guise of an A2A program one step further. In February 2021, a conservative lawmaker in Iowa introduced HB 515, which attempted to establish an “alternatives to abortion program” within the Iowa Department of Human Services. Had HB 515 advanced in the legislature, it would have diverted $880,000 in public dollars from Iowa’s general fund to pay for the program. HB 515 generated heated controversy over a paragraph in the bill. The bill’s language allowed the A2A program to take privacy invasion — as seen in other states’ A2A programs — a step further. The bill stated the program would “utilize proactive targeted digital marketing using proven search engine marketing techniques to reach pregnant women in real time who are in crisis and actively seeking an abortion.” In other words, public dollars would go toward a biased and invasive program to track people on the Internet in a twisted attempt to shame them out of seeking abortion care.

Texas Tactics Mirror Iowa

Resembling the tactics used in Iowa, Texas rolled out SB 802 in March 2021. SB 802, otherwise known as Texas’s “Every Mother Matters Act,” shares the same misleading title as Iowa’s HB 515. The key difference between Iowa’s and Texas’ legislation, however, is that Iowa’s bill attempted to create an A2A program, whereas Texas has operated one of the largest A2A programs in the US since 2006. Mirroring Iowa’s legislation, SB 802 in Texas required people seeking abortion care to receive a “pre-abortion resource access assistance” offer prior to obtaining an abortion. Strikingly similar to Arkansas’s and Iowa’s recent waves of A2A legislation, Texas’s SB 802 intended to invade peoples’ privacy and track A2A clients’ receipt of biased counseling via “de-identified” numbers assigned to them. However, as the Texas Tribune reported, earlier bill drafts required people seeking abortion to “...get an identifying number that would be stored in a state database.” Clearly, the similarities between the bills’ language across states is not an accident. Rather, this is further evidence of anti-abortion forces teaming up to increase their control over peoples’ personal healthcare decisions.

Anti-Abortion Rhetoric Disguised as Adoption Assistance

In February 2021, the Arizona Senate advanced SB 1254, which called for the Arizona Department of Health Services (DHS) to publish information about adoption agencies on its website, but with a caveat. The bill explicitly prohibits “agencies that counsel, refer, perform, induce, prescribe or provide abortions from inclusion on the list of agencies and services on the DHS website.” The bill also promotes AACs by forcing health officials to list “agencies that offer free obstetric ultrasounds and confidential counseling to women considering adoption placement.” In other words, actual medical clinics could be barred from the DHS website, while AACs are given extra promotion (and yet another opportunity to coerce people away from their abortion decisions).

Just like Arizona, both Maine and New Hampshire borrowed A2A program legislation tactics to promote AACs and restrict abortion access. Even though Maine does not have an A2A program, a bill introduced in January 2021 targeted funding for abortion and, instead, sought to establish “The Maine Foster Care and Adoption Initiative Fund.” LR 839 attempted to tie abortion restrictions to the establishment of foster care and adoption funding in a deceptive manner, similar to the way AACs operate.

In New Hampshire, the same tactics used in Maine are apparent. Similar to the way A2A programs solely allot money to AACs, HB 596 would force the New Hampshire Department of Health and Human Services to impose fines on abortion providers and use the fines to fund foster care and adoption initiatives provided by AACs. Supporting foster care and adoption services is not an issue on its own. Rather, the real issue is legislators actively harming healthcare professionals who are providing abortion care — under the guise of funding adoption and foster care programs.

Remaining Questions and Conclusion

The spread of A2A programs across state lines and the patterns observed among them present urgent opportunities for further investigative research. While Equity Forward has diligently tracked A2A programs in search of transparency, questions regarding how A2A programs are funded and operated still remain. How closely do anti-abortion groups work with elected and state agency officials to influence, establish, and run these programs? What roles do state health departments and human service agencies play in the creation and operation of these programs? Equity Forward is actively exploring these questions and intends to share new findings in the future.

Clearly, even though AACs claim to provide “free resources,” such as prenatal vitamins or diapers, to pregnant people, these “resources” doled out by AACs come at a cost. As Dr. Andrea Swartzendruber, a researcher studying AACs at the University of Georgia sums up, “‘they [AACs] cost people’s time and energy.’” The AACs know the people who come through their doors are likely to be struggling with the prospects of single parenting, with little financial support; dealing with unreliable and unaffordable access to healthcare; or facing challenges related to accessing basic needs, such as housing and groceries. While AACs may operate under the guise of “supporting” people, Nourbese Flint, policy director at Black Women for Wellness, makes it clear in a Vox article investigating AACs that “[AACs are] unfortunately capitalizing on a gap that we have in our system in terms of responding to the actual real needs of pregnant folks and the actual real needs of families.”

A2A programs are designed to deter people from abortion rather than actually helping the very people the programs are supposedly intended to serve. Struggling families who seek assistance via TANF programs to make ends meet need legitimate services and support. Taxpayers need accountability. Pregnant people need nonjudgmental, unbiased, and medically accurate reproductive health information. Time and time again, A2A programs fail to meet these needs and fall short of the care AAC networks claim to offer. A2A programs may vary slightly from state to state in terms of funding structure or name, but in all states, real people are negatively impacted by decisions to continually fund these faulty, biased A2A programs.

Editor's note: This report was updated in September 2021 to clarify Michigan's inactive A2A program infrastructure. Governor Gretchen Whitmer defunded Real Alternatives, which had operated the program, in a line item veto of the FY 2020 state budget. 

Rachel Wormer is a research intern at Equity Forward. Rachel brings experience within community research initiatives improving maternal, sexual, and reproductive health outcomes in both rural and urban areas. She is an advocate for reproductive healthcare access and intersectional, equitable public health practice. Rachel holds a master’s degree in public health policy from the City University of New York’s Graduate School of Public Health.