Dr Yashica Robinson is an optimist—and that, she says, is fortuitous. As one of the last abortion providers in Alabama, a willingness to see the bright side is practically a job requirement.
For much of the past year, Robinson, who is the medical director at the Huntsville-based Alabama Women’s Center for Reproductive Alternatives, and her staff have fought to overcome the challenges posed by COVID-19, while simultaneously battling a state effort to suspend all abortion services during the pandemic. “We will continue to be innovative and be creative and find ways that we will make this work,” she says, with characteristic resolve.
But there’s one topic that clouds Robinson’s confident disposition: her clinic’s limping finances. The truth, Robinson says, is that the economic fallout resulting from the coronavirus, combined with Alabama’s increasing restrictions on abortion, has hurt the clinic’s financial stability “tremendously.” When Alabama suspended “elective” medical procedures, including abortions, in late March, the Alabama Women’s Center cancelled a week of appointments. Even after a federal appeals court ruled that Alabama couldn’t block all abortions, Robinson had to file paperwork to justify each abortion she provided for the month the state’s emergency public health order was in place, adding time and costs to every appointment.
Most independent abortion clinics across the country are in a similar boat. Keeping clinic doors open during COVID-19 has required spending much more money—on cleaning and personal protective equipment, and on hiring more staff to facilitate social distancing rules that also reduced the number of patients who could be seen. At at the same time, 11 states temporarily suspended abortion services this spring, amid the growing pandemic. While all of those orders were blocked by courts or expired, the temporary closures and legal battles were financially devastating for independent abortion clinics. Meanwhile, as layoffs have spiked and businesses have gone under, patients have been less able to pay for their care, putting clinics even more in the red.
The result of this confluence of factors is that a growing number of independent clinics have closed their doors, according to a new report from the Abortion Care Network, a national association for independent abortion providers. This wave of shuttering continues a longer-term national trend. The number of independent abortion clinics in the U.S. has fallen 34% in recent years, from 510 in 2012 to 337 as of November. A total of 41 clinics have closed in the past two years alone. These closures have significant consequences for abortion access, as 58% of people seeking abortions get them at independent clinics.
While large, national abortion providers, like Planned Parenthood, are buffeted by similar headwinds, they typically have more resources and flexibility than independent clinics. Planned Parenthood, for instance, is a nonprofit organization, and so it’s eligible for some grants that independent clinics, which often operate as businesses, are not. National organizations also employ lawyers and lobbyists to influence politicians, while many independent clinics worry about meeting payroll for their frontline staff.
“There’s a lot of financial challenges to being a small business and being a small health care provider that is serving people with few resources,” says Nikki Madsen, executive director of the Abortion Care Network. “And those financial challenges were exacerbated as part of the pandemic.”
Abortion providers are accustomed to legal battles and restrictions imposed largely by Republican lawmakers. But with Roe v. Wade potentially vulnerable before an especially conservative Supreme Court, providers argue that now is the time that states must maintain access to abortion. The pandemic is making that nearly impossible.
Challenges from all sides
In addition to some states’ efforts to restrict abortion during the pandemic, independent abortion clinics have faced a host of other financial hardships.
Scheduling and travel changes spurred by COVID-19, for example, have also added to clinics’ costs this year. Whole Woman’s Health has seen several of its abortion clinics move from regular business hours to provide services 12 hours a day, split between two staff shifts, according to Marva Sadler, the group’s director of clinical services. Travel restrictions were posing difficulties for Whole Woman’s Health doctors in Texas, many of whom usually travel to provide abortions, so one doctor temporarily relocated from California to McAllen, Texas to keep that clinic running this year. When Texas temporarily banned abortions during its initial coronavirus order this spring, Whole Woman’s Health also spent time and money helping patients fly to abortion clinics in other states. Those resources could have been used to help more patients, Sadler notes. “It’s a really proud moment for me that we were able to work with those women to get them the services that they needed,” she says. “But wow, what a waste.”
As these costs have spiked, revenues have plummeted. Most states restrict Medicaid funding for abortion and some prohibit private insurance from covering it as well, meaning many patients can’t afford an abortion in a normal year. With so many Americans out of work due to the pandemic, that has only gotten worse. Abortion funds, outside groups that typically raise money to help patients cover the cost of their care, are strapped too. Robinson says her clinic in Alabama has gotten memos from abortion funds saying they need to limit how much money they can allot for patients at each clinic. “As long as I’ve been a provider, I had never heard of this,” Robinson says.
When independent abortion clinics do close because of these increasing obstacles, that can leave patients in some parts of the country with severely limited access to abortion and other health services. Five states have only one abortion clinic remaining, according to the Abortion Care Network report, and a number of others rely completely on a small number of independent abortion clinics. And while most abortions take place during the first trimester of pregnancy, when someone does need an abortion, later on, independent clinics are more likely to provide those services. Independent clinics represent 66% of all clinics that provide abortions after 16 weeks, and after 22 weeks, independent clinics make up 81% of those providing care.
Once abortion clinics close, they rarely reopen. The startup costs and hurdles, including applying for credit, finding a space that will rent to an abortion clinic and complying with many state’s strict abortion laws, are particularly difficult for independent abortion clinics to overcome, says Madsen of the Abortion Care Network. Without these clinics, patients face scaffolding obstacles. They may have to travel farther, take more time off work, find more money to pay for a more complicated procedure—or they may simply be forced to give birth to a child they did not want.
In Alabama, there are just four abortion clinics left, each 50-100 miles apart. Alabama Women’s Center is the only one that offers abortions up to the state’s legal limit of 20 weeks gestational age and it frequently serves patients from Georgia, Florida, Louisiana, Mississippi and Tennessee. “Losing any one of these clinics could mean that there are patients for whom the right to abortion care would mean absolutely nothing at all because there will be no provider available for them,” Robinson says.
A patchwork of funding sources
To help address some of these financial challenges, the Abortion Care Network launched what it believes is the first centralized fundraising effort for independent abortion clinics. It has raised about $220,000 through its Keep Our Clinics campaign, but Madsen says that’s nowhere near enough. When the association surveyed its members at the end of March, clinics said they anticipated losing an average of roughly $50,000 per month. Abortion Care Network members have now requested more than $1 million in assistance.
These funds would help with operating costs, including buying PPE and cleaning supplies, paying salaries, offering hazard pay and paid leave to help clinic staff care for their children, and covering legal bills from the court battles that many abortion clinics already fought this year. Finding PPE has been a particularly challenging issue for some independent clinics, as they have less purchasing power than hospitals and vendors still sometimes have restrictions on which kinds of facilities they can prioritize. Robinson says she was able to get N95 masks when the National Abortion Federation, the professional association for abortion providers, brought clinics together to put in a group order earlier this year. But other times, orders for items as simple as Clorox wipes and gloves have fallen through or come in unexpectedly, making it difficult to budget on any consistent basis.
With coronavirus cases surging around the country, Robinson says her clinic and others like it are in immediate danger of closing or being no longer able to provide services to low-income women. In the nearly 20 years that Alabama Women’s Center has been open, it has never turned away a patient because they couldn’t pay, Robinson says. It’s now unclear how long she’ll be able to continue that tradition. “It is possible,” she says, “that we could get to a day where we won’t be able to provide the services for patients.”
For now, Robinson’s optimism is at war with the reality of her clinic’s balance sheet. She says she knows her staff is committed and promises that they’ll fight to keep the clinic going. But “if things continue or get any worse than they are right now,” she adds, “I don’t know how we’re gonna do it.”