Last year, the Texas legislature approved a $350 million cut in Medicaid reimbursement rates to early childhood intervention therapists and providers. The cuts, made to help balance a billion dollars in property tax relief, affect the most vulnerable Texas children — those born extremely prematurely or with Down syndrome or other genetic conditions that put them at risk for developmental delay.

For months, providers of in-home physical, speech and occupational therapies have continued to serve children who have disabilities, despite mounting financial losses. Now some have had to shut their doors, curtail services or halt their home-visit programs, leaving many children without treatments their parents feel are crucial to the kids’ well-being.

That’s what’s happened to 2-year-old Haylee Crouse, who lives with her three brothers and sisters in the small town of Whitehouse, in East Texas. When she was just 8 days old, Haylee contracted newborn meningitis. It left her with some mental and physical deficits, and she started having periodic seizures.

But at the age of 9 months, Haylee started getting home visits and treatments from physical, occupational and speech therapists, several days a week. The therapists worked for the non-profit Andrews Center, in Tyler, Texas. Amanda Crouse, Haylee’s mother, said the therapists have made all the difference in the world for her baby girl.

“They were a lifesaver to her and to our family,” Crouse said. “They worked her hard. For example, she was not rolling over. They taught her how to roll over. They then taught her how to crawl, pull up on the couch and then, finally, she learned how to walk.”

Today, Haylee walks and laughs and is learning to talk. But all this progress is now at risk, her mother says. The state’s cuts to its Texas Medicaid Acute Care Therapy Programs have meant that the one provider of early childhood intervention treatment in Tyler — which has provided in-home therapy to hundreds of families in five East Texas counties — can no longer do so. And so, that’s it.

On the 2-year-old’s last day of therapy, Crouse said, “her therapist actually cried. Gave her a hug, said goodbye. We took a picture, just to kind of document that moment. And it was an emotional day.”

As news of the cuts became public, parents and grandparents of children who have disabilities flocked to Austin in March to implore the state Senate not to do this. Mothers wept in frustration as they testified before the Texas Senate Finance Committee about the vital these early interventions play in their children’s quality of life.

“This is Elijah,” Mary Castro told the committee members that day, holding up a photo of her 2-year-old son. “When my son was born, my husband and I found out eight days later that he has Down syndrome. He’s medically fragile and developmentally delayed.”

Without the support of early childhood intervention therapists that Medicaid provided, Castro told the lawmakers, “Elijah would not be walking, signing, doing word approximations, dancing to music, or interacting with his peers. With that said he is delayed. Quite delayed. But we love him, and he loves people.”

Republican Sen. Jane Nelson, who heads the Texas Senate’s finance committee, tried to reassure Castro and other anguished parents that the state would make sure there would be no interruption of services, whatsoever.

“Every eligible child for these services will continue to receive them,” she told the parents. “And we’re going to monitor it and we’re going to make sure that happens.”

But that’s been a promise the state has not been able to keep, and it’s in the rural parts of Texas where collapse of service has already begun.

“Sometimes you need to come out to these rural areas and see how things are done — and how they have to be done — and even talk to some of the parents before you just decide to cut a program,” said Waymon Stewart, the executive director of the Andrews Center in Tyler.

Stewart predicts that children with profound disabilities will suffer most from the closure of his program and others like it, especially in rural regions. It’s not uncommon for early childhood intervention therapists to have to drive an hour each way to get to far-flung patients. For children who are prone to seizures, or who have to be connected to machines for daily living, long trips in the car several days a week for treatment in other clinics are simply not going to happen, he says.

The cuts made in the state capital took a $312,000 bite out of his center’s budget, forcing him to terminate 20 employees.

“It really hit us hard,” Stewart said. So we were really digging into reserves to try to make this program last, and we did for a year.”

But after that, he said, “we just decided to give our notice. We couldn’t continue to do it unless the rates were changed.”

In Wichita Falls, 235 miles away, the same thing has transpired at the North Texas Rehabilitation Center, which serves 10 North Texas counties. Mike Castles, the center’s president, said they hung on for a year, but it cost them more than $200,000 in losses. So, after 30 years of service to thousands of North Texas families, that’s it for them too.

“It’s all about money,” he said, “and it created some internal problems financially with our other programs as well. There’s just so much money to make this all work. We tried to for a year; it got worse instead of better with even more bad news coming for this fiscal year.”

The state is actively hunting for new therapy providers. But the trick is finding new providers who can make work the same difficult financial circumstances that drove previous health providers out of the program.

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When Mike Stabile first moved to Los Angeles in 2011, he was struck by a freeway billboard that showed a line of cocaine and an overturned shot glass. The caption read: “You know why. Free HIV test.”

“I literally pulled over the car and was like what’s going on?” Stabile remembers. “I was having a panic attack.”

He describes another billboard showing two men in bed, looking nervous, and posing this question: “Trust Him?”

“As a gay man, you really have to fight against this idea that you’re constantly in danger,” says Stabile, who came of age during the height of the AIDS epidemic in the ’80s. “Fear and stigma actually works against people getting tested.”

Stabile is a documentary filmmaker, activist and a spokesperson for the Free Speech Coalition, the trade association for the adult entertainment industry, which is opposing Proposition 60.

He says he sees the same heavy-handed, moralistic attitude behind Proposition 60, the California ballot initiative that would require adult film performers to use condoms on porn sets. If the performers don’t comply, and state regulators fail to enforce the mandate in a timely manner, any Californian can sue the film producer.

“Its success depends on stigma around sex, stigma around porn,” says Stabile.

The man behind Proposition 60 — and all those billboards — is Michael Weinstein, president of the AIDS Healthcare Foundation and a longtime maverick in gay activist circles.

The nonprofit runs pharmacies and provides HIV care in 13 states and 37 countries, and it gave away 38.5 million condoms last year. It’s putting $4.5 million from its pharmacy sales into backing the Proposition 60 condom mandate. (It has also put $14.7 million behind Proposition 61, Weinstein’s initiative aimed at lowering prescription drug prices in California.)

Weinstein says he’s steadfastly promoting condoms when other groups seem to have forgotten them.

“It’s unfashionable,” he says. “I was on a panel discussion and one of the guys said, ‘You’re acting like our mother telling us to wear galoshes.’ And my reaction was ‘Yeah, somebody needs to do that!’ I mean, I’m not trying to win a popularity contest, obviously.”

For Weinstein, Proposition 60 is primarily about protecting adult film workers against sexually transmitted diseases — at a time when infection rates are at a 20-year high across California. But it’s also another large-scale condom campaign.

“A lot of people get their sex education through these films, and I think it’s sending a bad message,” Weinstein says. “I don’t want young people to be educated that the only kind of sex that’s hot is unsafe sex.”

Weinstein has long taken controversial positions, but he’s often landed on the right side of history. In the 1980s, he fought lawmakers in California who wanted to quarantine AIDS patients. When nurses were afraid to touch patients, leaving them languishing in the hallways of county hospitals, he helped set up one of the first AIDS hospices, where people could die with dignity and compassion. And when AIDS drug cocktails became available, Weinstein risked bankruptcy to provide the life-extending drugs to uninsured patients.

“We decided we had a moral obligation to give them, and we paid for them and those people lived,” he says.

One of Weinstein’s more recent and most unpopular stances is on pre-exposure prophylaxis, or PreP, the daily pill that can prevent people from contracting HIV. Many activists consider it a powerful tool for prevention.

Weinstein doesn’t see PreP that way. “It’s often taken in conjunction with crystal meth and other party drugs,” he says. “It’s really a get-out-of-jail-free card.”

He says it gives people a free pass to not use condoms and be reckless, driving a rise in other STDs, which recent studies bear out.

But other public health groups say PreP will reduce HIV transmission and save lives, which the studies also support. “It’s not helpful to have one of the largest HIV organizations in the world trivializing it or downplaying its importance,” says Courtney Mulhern-Pearson, director of state and local affairs at the San Francisco AIDS Foundation.

Her group, along with AIDS Project LA, is opposed to Proposition 60, in part, because it ignores PreP. Mulhern-Pearson says Weinstein’s singular focus on condoms is outdated and unrealistic.

“Condom fatigue is real,” she says. “And I think that all of us are probably not realistic and not forthcoming about our condom use.”

History and opposition

Weinstein has been fighting to mandate condoms in adult films for years. While federal and state worker safety laws technically already require producers to protect performers against STDs with condoms, the law is largely ignored and poorly enforced. Weinstein has pushed California’s Division of Occupational Safety and Health, known as Cal/OSHA, to refine and clarify its regulations, without success. He’s backed local measures in Los Angeles County to require condoms, which passed, but enforcement has, again, been minimal.

At every turn, the adult film industry has fought the condom mandates. Some say it would force them to make products that won’t sell, or that it would drive the business underground or out of state.

In mid-October, more than a hundred adult film performers rallied outside Weinstein’s office in Los Angeles to protest Proposition 60. They chanted slogans like “Our Bodies, Our Choice!” and carried signs that read “Where is Weinstein?”

They say they prefer to rely on the industry’s bi-monthly testing protocol over condoms. Performer Ela Darling says condoms don’t work on porn sets; they’re uncomfortable and cause friction rashes.

“The sex you have on camera isn’t like the sex you have at home,” she says. “It’s like Olympic-level, athletic sex.”

She’s frustrated that Weinstein is ignoring performers’ concerns.

“He will not hear us, he will not speak to us, but he’s happy speaking for us,” she says. “And that’s the problem.”

Weinstein defends his refusal to meet with the adult film industry.

“I’m not going to put myself in a position of debating people where all they do is call me names,” he says.

Weinstein’s critics have called him bombastic, a bully. They compare him with Donald Trump. They post tweets that refer to him as the “Condom Nazi.”

“In case they haven’t noticed, I’m Jewish and I’m gay, OK?” he says. “It makes my skin curl.”

Weinstein says he’s never liked the limelight. He’s had to develop a thick skin to stay in this business, to stand up for what he believes is the moral thing to do, for what he believes is his responsibility toward young generations.

Yet it’s clear that the criticism bothers him.

“He’s been hurt,” says Sharon Raphael, an old friend and fellow activist. “I know that it hurts him.”

Still, she adds, everyone knows he’s a force to be reckoned with.

“When most people would be down and out, strike three, he’d get up again,” she says. “He never gives up. Ever.”

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

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