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Real Waste: Public Records Elucidate Real Alternatives' Role In Indiana's Alternatives to Abortion Program

Jack Dobkin, Former Research Associate | Public Records

Introduction

As Equity Forward has reported, a number of states in the United States operate Alternatives to Abortion (A2A) programs, which funnel state and federal funds to anti-abortion centers (AACs), whose purpose is to shame and deceive pregnant people and parents and convince them not to seek abortion care. Indiana is one of more than a dozen states with an A2A program. The Indiana Parenting and Pregnancy Support Services Program was first established in near secrecy in 2015 and has been renewed every fiscal year since. Since the beginning, it has been administered by Real Alternatives, a Pennsylvania-based national anti-abortion organization that Equity Forward has been following for years. Equity Forward opposes state interference with the decision-making process of pregnant people and does not believe funding should be awarded to carry out this work. Equity Forward also opposes the misuse of or opaqueness in how public dollars are spent — transparency, accountability, and good governance are pillars of a healthy democracy, as is bodily autonomy. Real Alternatives not only restricts the agency of pregnant people, it also has a history of corruption and shady financing — the organization has previously prompted investigations from Pennsylvania’s Auditor General and even had its contract in Michigan terminated after a kickback scheme was uncovered. 

We at Equity Forward don’t believe that the state should be in the business of complicating the decision-making processes of pregnant people, nor do we believe that contractors who receive money from taxpayers should be misusing, profiting from, or otherwise misleading taxpayers about how their dollars are spent. In partnership with All-Options Pregnancy Resource Center — which provides support, resources, and referrals for comprehensive pregnancy care, including abortion care in Indiana — we filed public records requests for budgets, annual reports, and other financial information for Real Alternatives’ A2A program in Indiana for Fiscal Year 2017-2018 through Fiscal Year 2020-2021. What we found were some concerning trends and lots of unanswered questions. The analysis provided here is based on the productions we received, which consist of the “Year in Review” annual reports, and monthly invoices for reimbursement, both submitted by Real Alternatives to the Indiana State Department of Health (ISDH) for the years in question. Per Real Alternatives’ contract with ISDH, these self-reported documents are the only level of “accountability” or “transparency” required for the state’s A2A program. Based on Real Alternatives’ regular lack of transparency and fiscal irresponsibility, we have no reason to trust that these numbers are accurate or comprehensive. However, owing to Indiana’s flawed contract with the organization, these self-reported data are all that the public has access to learn more about the inner workings of the state’s program that publicly funds anti-abortion centers. This type of transparency and accountability is important always, but especially in a post-Roe world, as the anti-abortion movement attempts to position AACs as legitimate sources of care for pregnant people while advocating for increased funds to state A2A programs — which as the records below suggest serve as money-making machines for the anti-abortion movement.  

After receiving and reviewing 471 pages of public records from Indiana’s State Department of Health, Equity Forward has identified the following trends.

Analysis

Many Gaps, Questions, And Missing Dollars Exist In Spending By Real Alternatives On Indiana’s A2A Program

Each year, the documented money spent per the invoices submitted by Real Alternatives to the state does not equal the documented money awarded to these subcontractors per the year in review. This lack of spending down the total grant money raises some questions:

  • Why does Real Alternatives maintain the ability to be reimbursed for so much money, if there is a documented history of not spending it all? This artificially inflates their profile and relative power/importance in the landscape of Indiana “healthcare.”

  • Does the state not require Real Alternatives to account for every dollar it receives?

  • Where has the money that Real Alternatives has not spent been redirected to, if so? How could it be better spent?

Based on the records received by Equity Forward, there appear to be missing invoices for the first three months of FY2017-2018. This may explain why the documented money spent via invoices submitted to the state does not match the documented money awarded to these subcontractors per the year in review. However, this discrepancy remains for the following fiscal years, in which all invoices appear to be accounted for.

Real Alternatives’ spending on administrative costs tends to run between 4-10% of total monthly costs. The 3-month period of services rendered from April 1, 2020, to June 1, 2020, witnessed a massive spike in the proportion of monthly administrative spending — to 15%-25% monthly.

  • This timeframe roughly corresponds to the initial onset of the COVID-19 pandemic, during which it was common for expenses to increase as the world adjusted to life in a pandemic — potentially providing an explanation here.

  • However, dollar spending on administrative costs noticeably increased, while spending on services dropped significantly. If Real Alternatives is a service-based provider, why should the administrative costs go up so much while need dropped so greatly?

  • This further illustrates a picture of money going into Real Alternatives’ pockets rather than toward any real, material assistance for pregnant people in need — which is the true goal of the federal Temporary Assistance for Needy Families (TANF) program that Real Alternatives pretends to comply with.

Total costs tend to spike (sometimes marginally, sometimes significantly) toward the end of each contract period. Although this regularly happens with grant spending, it raises serious questions for a grant meant to cover needs-based services:

  • If Real Alternatives is a service-based provider, it is reasonable to assume that there could be times when need increases. However, why would this period so regularly coincide with the end of a contract period?

  • As far as Equity Forward is able to determine, Real Alternatives is not required to offer reasoning for the spikes. Are they attempting to spend down the budget to create the impression of more need than actually exists? It certainly appears that Real Alternatives is attempting to prove the “effectiveness” or “worth” of the large funding they receive and the existence of this harmful program.

The Breakdown of Programmatic “Services” Reported By Real Alternatives Is Vague At Best; Regressive And Harmful At Worst

Most AACs are not licensed medical providers, despite many manufacturing the appearance as such, in order to deceive and manipulate pregnant people. Although most AACs are not licensed medical providers, and are almost never staffed by licensed medical personnel, regularly over half of visits to AACs in Indiana’s A2A program are self-reported as offering “counseling” on fetal development, medical/health issues, and pregnancy information. Other trends in “services” provided by Real Alternatives subcontractors raise serious concerns about how pregnant people are being advised and cared for in Indiana.

Ninety Percent Of Program Funds Are Funneled To Women’s Care Center

Nearly 90% of subcontractor grants are awarded to Women’s Care Center and its affiliates annually. Women’s Care Center is run by Ann Manion, a politically connected anti-abortion activist in the state.

  • On average, from FY2017-2018 through FY2020-2021, Women’s Care Center and its affiliates annually received about 90% of funding awarded through Real Alternatives’ A2A program in Indiana.

  • Other regular recipients include Heartline Pregnancy Center; Matrix Life Care Center; Evansville Christian Life Center; Catholic Charities of Fort Wayne/South Bend; A Mother’s Hope.

This reality raises the question — if one entity regularly gets ~90% of state funds, what meaningful role does Real Alternatives play?

Real Alternatives’ Reporting For TANF Compliance Is Vague And Raises Questions.

Real Alternatives receives federal funds from the TANF program — a common source of funding for A2A programs across the country. The TANF program exists to provide material assistance to parents and families in need of monetary support. A2A programs have latched onto the program’s vague details about how to provide such support, and egregiously use the funding to prop up their harm.

Reporting for TANF compliance only exists in vague, self-reported terms about Real Alternatives’ self-determined nature of each visit. Real Alternatives only states the purported TANF purpose, and the self-reported number of clients that they deem to fall in that category, by county.

Annotated Records

Explore our full annotated public records analysis below through DocumentCloud. (Technical notes: All hyperlinks below will open in the same tab; please right-click on your browser and select Open link in new tab. If you want to view only the annotations, click Notes from the drop-down menu in the bottom-left corner of the interactive report.)

Conclusion

As long as Real Alternatives continues to run the A2A program in Indiana and maintains its presence in other states, Equity Forward will continue to monitor, investigate, and hold the organization and those elected officials who back it accountable for the harm they inflict on pregnant people and parents. Especially in a post-Roe world, all people should be able to get accurate information about all their options so they can decide what is best for their health and well-being. No one should be deceived or manipulated when they are seeking support for pregnancy options, parenting, or health care. AACs should not be allowed to engage in unscrupulous tactics and should be required to be transparent about who they are and what services they do and don’t provide. States need to provide greater scrutiny, investigation, and regulation of A2A programs, especially those that rely on taxpayer dollars.

Acknowledgments

Equity Forward thanks All-Options Pregnancy Resource Center for their collaboration on this report.

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