In Vestal, N.Y., a town on the border with Pennsylvania, Dr. Amy Cousins runs an independent abortion clinic serving women in New York and northern Pennsylvania. It's the only abortion provider in the area that accepts Medicaid, the government-sponsored health insurance for low-income people, and this is causing them financial problems.
Abortion access has dominated the news cycle recently. All of the questions surrounding it -- the morality of it, how much it should be legislated, how much federal funding clinics preforming them should get -- have centered around Planned Parenthood. With 700 health centers and an annual revenue of almost $200 million, Planned Parenthood is undoubtedly a resource for countless women. But what seems to be lost in the discourse are independent abortion providers, which are also facing their own set of problems -- even in states with liberal policies on abortion.
Nikki Madsen, executive director of the Abortion Care Network, estimates that independent clinics performed about 66 percent of abortions in 2011, which is the most recent data available. For all of the debate about Planned Parenthood, the organization performs less than a third of all abortions in the U.S.
In a blue state like New York, independent clinic workers don't have to worry much about restrictive legislation that's caused abortion clinics in other parts of the United States to close. But they do have another big problem that's making it hard to stay open: low Medicaid reimbursement rates.
"Independent clinics often serve individuals and families in the most rural parts of our nation and those with the least financial resources," said Madsen. "There is no safety net for these women, people and families without independent abortion care providers."
Only 17 states let Medicaid funds cover an abortion that isn't a product of rape, incest or endangers the life of the mother. So independent clinics have to rely on volume of abortions, as well as community support, to operate. Clinics can choose to stop accepting Medicaid, as some Planned Parenthood and private clinics have done, but that means women travel longer distances to get one.
“Medicaid is notorious for paying low and slow," said Peg Johnston, director of Access for Women, a company that manages the clinic. "Currently the clinic is only reimbursed $230 for its first trimester abortion services, and that’s a number that hasn’t changed in 20 years.” The average cost of the abortion pill, an option for women up to nine weeks pregnant, is $490.
Because New York made more low-income people eligible for government-sponsored health insurance in recent years, about 30 percent of the population now relies on Medicaid. “This means we’re often reimbursed for just 50 percent of the work we do. It’s a stretch to keep our doors open, and I don’t see an end in sight,” she said.
Because the Medicaid reimbursement rates aren't high enough, independent abortion clinics, which provide the majority of abortions in America, are closing just as often if not more than Planned Parenthood clinics. In 2011, there were around 500 independent abortion providers in the U.S. Since 2013, that number has dropped below 400.
“It’s a scary time for abortion access, beyond just the terrorism aspect of things,” said Madsen.
Each year Planned Parenthood receives around $500 million in government grants and almost $400 million in private donations. That kind of support makes it easier to stay open when legislation cracks down on abortion access.
Unlike Planned Parenthood, the majority of independent clinics are for-profit, "so they don't have the ability to fundraise from the public or the state and federal government to subsidize care," said Madsen. The majority of care most independent providers provide is abortion care -- in fact many exclusively provide abortion care and contraception. Planned Parenthoods often provide a wider range of services, which means more revenue, she said.
In states that didn’t opt to make more people eligible for Medicaid in recent years, or don’t let Medicaid cover abortions, clinics have freedom to set their rates and will often require a woman to foot the entire bill. In these states, it's common to see the price of an abortion go up week-by-week in a women's pregnancy. For example, at a clinic in Arizona that doesn't accept insurance, an abortion at 14 weeks is $740, jumping up to $1,080 at 17 weeks.
“Independent clinics in red states ... have legislation to worry about. But the ones that are still open typically only accept cash or credit cards, which is easier for keeping the doors open,” said Johnston.
Legislation has disproportionately impacted independent clinics in red states, especially Texas, which passed a law in 2013 requiring clinics to meet the standards of outpatient surgery centers. As a result, 23 clinics -- only four of which were Planned Parenthoods -- either closed or stopped providing abortions. The U.S. Supreme Court agreed to hear a challenge to the law, but abortion advocates say even more clinics throughout the state will close if it is deemed constitutional.
“Most of those clinics that closed were independents because they weren’t able to gather resources or funds to meet the requirements of the law," said Vicki Saporta, president of the National Abortion Federation. "And they likely aren’t coming back."
The deadly shooting last month at a Planned Parenthood center in Colorado Springs, Colo., also has clinics thinking about security measures.
Planned Parenthood doesn't divulge how much security is in place at every Planned Parenthood, simply stating it is “extensive.” Some, like the one in Colorado Springs, have safe rooms to protect staff and patients in case of an attack.
But struggling to stay afloat, independent abortion clinics often lack sufficient security.
The last clinic in Mississippi to offer abortion services, which is independently-run, lacks funds to employ security and relies on “clinic escorts” to keep the place safe. These are volunteers who greet patients outside and ensure them a safe passage through protesters.
"Clinic escorts" volunteer to protect the staff and patients at Jackson Women's Health Center, the only abortion clinic in Mississippi. (AP)
“You can’t do the kind of work we do in a bunker. Terrorism can be anywhere, but the idea that places of medicine need ‘safe rooms’ is baffling to me,” said Johnston.
While Dr. Cousin’s office hasn’t had an uptick in threats of violence recently, she’s used to protesters outside of the small clinic.
“It’s a presence that’s always there, so it’s become background noise for us," she said. "Not for our patients, mind you, but for us it’s a part of our everyday life."
But as these independent clinics close, it opens up more problems for lower-income women. A 2013 study at the University of California at San Francisco found that a woman who felt forced to carry a pregnancy to term because she wasn't able to get an abortion was three times as likely to be below the federal poverty line two years later.
"Research shows us that without access to affordable abortion care, women carry unwanted pregnancy to term or take matters into their own hands. Those who are forced to carry pregnancies to term are less likely to be able to escape poverty and more likely to stay in an abusive relationship," said Madsen. "There is no doubt that the sustainability of independent abortion providers is directly tied to the overall health and well-being of women and girls lives."