Planned Parenthood’s rallying cry has long been “our doors stay open.”
It’s been a defiant response to decades of attacks—political, legislative, and physical—against the nation’s largest provider of reproductive health care.
Cecile Richards repeated that promise at the Women’s March on Washington last month, in reference to statements from House Speaker Paul Ryan that defunding the organization will be a top order of business for the new Congress.
But if Congress follows through on Ryan’s promise, many of the organization’s clinics may be forced to close, according to interviews with Planned Parenthood officials in numerous states.
And, according to many of those officials, defunding could hit certain “pro-choice” states the hardest, with services in some areas effectively obliterated.
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“If we do not get federal reimbursement for the care we provide, our health centers will close,” Beth Parker, chief legal counsel of Planned Parenthood Affiliates of California, wrote in comments that she provided to Rewire. “Our patients will have nowhere to go.”
Asked why she was making this alarming statement publicly, Parker said, “People need to know that this is what will happen.”
States that have been traditionally seen as pro-choice could be hit harder by a loss of federal funding because those states have, in general, favored interpretations of laws and rules that allow Planned Parenthood to receive reimbursements for basic health care, including family planning services, to low-income patients.
As a result, Planned Parenthood affiliates and other reproductive care providers in some pro-choice states have become particularly reliant upon federal funding for their services, Parker told Rewire.
They are therefore especially vulnerable to the prospect of that funding drying up.
Parker said the states most at risk, in order of reliance on federal dollars as a percentage of revenue, would likely be California; Oregon; New York; Wisconsin; Minnesota; and Washington state.
“If this federal funding goes away, Planned Parenthood—and California—stand to lose $265 million,” Parker wrote. “This represents almost 80 percent of our affiliates’ operating revenues. If this funding source stops so does our ability to provide health-care services to the most vulnerable in our state.”
According to the most recent annual report from Planned Parenthood Federation of America, affiliates collectively receive 43 percent of their total funding from government health services grants and reimbursements.
None of these federal funds cover abortion. Instead, they pay for cancer screenings, testing for sexually transmitted infections (STIs) such as HIV, and contraceptives, among other services.
Republicans have for years introduced bills that would “defund” Planned Parenthood through various means, but the term itself is imprecise.
The biggest source of federal revenue that goes to most Planned Parenthood affiliates is in the form of reimbursements for medical services already rendered to people who qualify to Medicaid, usually due to their low income. The second-largest source is via the family planning program known as Title X. Received in the form of block grants, Planned Parenthood affiliates often sub-grant Title X money to other small, independent clinics that frequently serve rural areas.
Speaker Ryan’s plan seems to be to strip Planned Parenthood of eligibility to receive reimbursements through Medicaid. Sen. Joni Ernst (R-IA) recently introduced a bill that would go even further, banning the organization from receiving any federal funds.
In a background interview with Rewire, a spokesperson for Planned Parenthood Federation of America said that while similar bills have been unsuccessfully introduced in the past, the threats to defund the group haven taken on a more serious quality this year because of the Republicans’ dominance in both houses of Congress, and because of the Trump administration’s open hostility to abortion rights and reproductive care as a whole.
To understand the severity of the problem, take the example of California. Between seven separately incorporated nonprofits, Planned Parenthood of California runs 115 health centers, serving nearly 900,000 patients each year. These patients made a collective 1.5 million visits last year, according to Parker’s figures.
Since nearly 90 percent of those patients earn incomes close to or below the federal poverty level, they qualify for Medi-Cal, California’s Medicaid program. Under this arrangement, Planned Parenthood receives reimbursement for the services it provides to those patients. For the non-abortion services provided by Planned Parenthood in California, the state provides 10 percent of Medicaid funding while 90 percent comes from federal dollars, Parker said.
It’s hard to see how that gap—the $265 million Parker cited—could be filled by alternative sources, year in and year out.
As with almost all issues relating to health care in the United States, the picture differs, sometimes dramatically, from state to state. The Planned Parenthood officials who spoke with us were at pains to point out that not all states would be affected similarly by a federal ban on funding, and that there was not always a clear difference between pro- or anti-choice states.
For instance, Wisconsin is home to perhaps one of the most ambitiously anti-choice governors, Scott Walker, who has led an assault against abortion rights during his term as governor, with support on the national stage from Speaker Ryan, the man now leading the push to defund Planned Parenthood.
Some 60,000 residents of Wisconsin rely on Planned Parenthood for their health care, said Nicole Safar, director of government relations at Planned Parenthood of Wisconsin. Of those, 50,000 people are Medicaid patients. Medicaid reimbursements comprise around 44 percent of Planned Parenthood’s revenues in that state, Safar said. Combined with the $3.5 million received in Title X grants, federal funds make up nearly 60 percent of Planned Parenthood’s revenues in Wisconsin.
“If the federal defunding happens, it will have a significant impact on our ability to provide care. I don’t want to mince words. It will be devastating for women in Wisconsin,” Safar said. “The idea that these doors stay open is very much what drives us every day. If there are three sets of doors or two sets of doors, our staff and supporters are going to continue to be resilient against attacks on our patients and their ability to get care. I don’t think we’re at the point today where we’d make guesses about which clinics stay open and which don’t. We are still committed to stopping this and mobilizing our supporters and patients and partners, to stand up against these attacks.”
Safar pointed out that 21 independent health-care providers receive Title X funds through sub-grants from her organization. Those centers serve mainly rural and poor communities that do not have other health-care providers, in many cases.
Connie Lewis, executive vice president of external affairs at Planned Parenthood Minnesota, North Dakota, South Dakota, said that the Planned Parenthood in Minnesota derives 33 percent of its revenues from federal funds—a relatively small percentage compared to California, but a substantial portion of its total funding and certainly enough to affect its ability to provide current levels of service.
The spokesperson for Planned Parenthood for New York did not provide the overall state figures by deadline. But Carrie Mumah, a spokesperson for Planned Parenthood of New York City, said that affiliate would lose about $12 million each year, amounting to 22 percent of its annual budget. More than half of Planned Parenthood New York City patients are eligible for Medicaid, Mumah said.
Overall, many Planned Parenthood officials agreed with Parker’s assessment that the loss of federal dollars would generally hit pro-choice states the hardest.
For example, Planned Parenthood affiliates in several states with legislatures or governors hostile to abortion rights and reproductive care decided years ago not to seek Title X funds. In other instances, state laws have created a prioritization for the types of entities able to compete for federal funds, putting Planned Parenthood in last place. And in states that declined to expand Medicaid under the Affordable Care Act, many people who would otherwise be eligible to have their health care paid for by federal dollars instead go without.
Tennessee is one state that declined the Medicaid expansion under the Affordable Care Act. Because of this, relatively few Tennesseans are enrolled in Medicaid. In that state, Planned Parenthood receives only about 10 to 12 percent of its roughly $9.5 million annual revenue from Medicaid reimbursements, said Jeff Teague, president and CEO at Planned Parenthood of Middle and East Tennessee in an interview with Rewire. The affiliates in that state do not receive Title X funds either, he said.
Teague agreed with the sentiment that affiliates in pro-choice states would be more susceptible to federal defunding than those in states where lawmakers have limited reproductive and sexual health care, at least in the short term.
“The other states have a very favorable culture and environment related to health care, but especially reproductive and sexual health care,” said Teague. “We have learned to be resilient and survive and continue to provide health care as best we can without the benefit of those programs.”
In practice, that means many patients pay for services out of pocket, or using health insurance provided through their jobs. Teague said his organization has also learned to be as aggressive as possible with private fundraising through individual donations and grants from foundations.
That approach, said Teague, is common for reproductive and family planning providers in southern states, where there is a lack of basic health-care services. The shortage of those services results in dismaying statistics on maternal and infant mortality, and STI rates, in the South, he said.
“We’re talking about people’s lives,” he said. “Women not being able to control their reproductive and sexual health and their reproductive lives, often does have the additional tragic effect of trapping them in poverty.”
All the Planned Parenthood officials we spoke with stressed the fact that cutting federal funds would have devastating effects in all states, regardless of whether they are “red” or “blue.”
They also rejected the notion put forth by anti-choice leaders that other health-care providers could take on Planned Parenthood patients if the organization’s clinics vanished.
That argument has been demolished by the federal government’s own agencies, and as Rewire reported in 2015, many of the “entities” named by anti-choice advocates as alternatives to Planned Parenthood were elementary schools, jails, and homeless shelters that did not, and could not, provide similar care in Planned Parenthood’s absence.
Independent family planning providers we spoke with also voiced their alarm at the prospect of Planned Parenthood being stripped of federal funds, despite the fact such a move could arguably create a windfall for providers that are not linked to the health-care organization.
Mary Wynne-Peaspanen is the executive director of the Family Planning Association of Northeast Ohio, which serves three counties to the east of Cleveland, providing family planning, cancer screenings, contraceptives, and STI testing and treatment.
“Even if we continue to be funded, if Title X remains intact, if Planned Parenthood is defunded, their capacity to serve clients is incredible,” Wynne-Peaspanen said. “We’re certainly not in a position at the moment to take on all of their patients. So you know that clients are who is going to suffer because they’re not going to have equal access to services.”
Eileen Schnitger, director of public policy for Women’s Health Specialists of California, a small network of nonprofit, feminist clinics serving northern California, said that while her clinic does have some additional capacity, the big concern for her was that anti-choice politicians would not be satisfied with simply stripping Planned Parenthood of its funds.
“If there was a funding cut specifically to Planned Parenthood, we think we would be targeted five minutes later,” she said. Her clinic provides full family planning services, as well as adoption services and abortion care. “If the federal government said, ‘We’re going to cut Title X funding for clinics that provide abortions,’ that affects us and Planned Parenthood equally. So that’s huge.”
Indeed, Beth Parker of Planned Parenthood in California said that eradicating access to safe and legal abortion is, of course, the true aim of any defunding effort.
“It has been a long-standing strategy of the anti-choice movement to defund family planning providers—and specifically Planned Parenthood—as a means to end access to abortion in America,” wrote Parker. “They also want to end access to contraception.”