A Rural Clinic Operating Without a Net

By Katie McDonough | September 6, 2019 | 1:56pm

Justice Politics

The Mahube-Otwa Community Action Partnership is a nonprofit organization that operates a small network of family planning clinics serving low-income patients in rural Minnesota. Like so many other clinics across the country right now, it withdrew from the Title X family planning program after the Trump administration’s gag rule went into effect, prohibiting providers like Mahube-Otwa from receiving federal funds if they counseled or referred patients for abortion services.

The decision to opt out of the program was painful but straightforward enough, executive director Liz Kuoppala told Jezebel, since staying in the program would have meant rejecting the patient model that anchors the work they do in their communities: “Being client–focused means providing the very best service we can to our clients and not having a politician dictate what sort of services we can provide,” she explained. “So being limited just in order to get a grant is just contrary to who we are and how we operate.”

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But the fallout has been chaotic. The loss of funding meant a 50 percent staff reduction, increased expenses around medication and other services, and a difficult tightrope to keep from passing those costs on to patients. They are trying to find alternate funding sources, but “these are very high–poverty counties,” Kuoppala said. “There’s not a lot of resources out there but we’re trying to shake the trees for what we can find.”

Jezebel spoke with Kuoppala and Chandler Esslinger, the organization’s community health coordinator, about navigating an uncertain future with fewer staff on hand and a tighter budget. Our conversation has been condensed and lightly edited for clarity.

JEZEBEL: Can you tell me a little about the work that your organization does?

CHANDLER ESSLINGER: So the day-to-day initiatives that we have really mostly revolve around keeping our clinics open. We have four standing locations, and traditionally almost all of those spaces have been open at least four days a week. We have four other satellite locations, and those are all open once a month.

We have a variety of services that we provide. We have some walk–in services like for STI testing and things like that, but usually we have a nurse in the clinic and, on clinic days, we have a provider in the building and that’s when we’re able to provide more birth control services, pap smears, annual exams, more in-depth consultation. And then we do a variety of different kinds of outreach. Last year we had a very strong initiative to promote the Gardasil vaccination as cancer prevention, and then we also provide a variety of different educations in the community—some with our local schools, some with other local non-profits, some with treatment centers and things like that.

A lot of the communities that we serve have higher rates of poverty—85 percent of the clients we see qualify for our sliding scale services based on their income. And then a large subset of the population that we work with are people who we would consider either underinsured or uninsured—so folks who have high deductible plans where it’s not necessarily feasible for them to go to a clinic and receive the kind of care that they need without some sort of financial assistance. And about 50 percent of the folks we serve travel 10 miles or more for services. And so that’s kind of the group of folks that we’re catching. We know that health care is a very personal experience, and sometimes when people don’t have an experience that is affirming or culturally competent, folks search elsewhere to get care. And so we find ourselves serving a lot of patients who maybe don’t feel fully supported by traditional healthcare systems.

As we decrease hours and decrease flexibility for seeing patients, it really creates hardship

The domestic gag rule had been a rumor for a long time before it became real. When did you all start planning for different outcomes?

LIZ KUOPPALA: I’d say we were really hoping that it was just politics, that it was just talk and wasn’t really going to happen. And partly I think we were hoping that just because we knew it would have a catastrophic effect on our services. But a few days before it came down, we did an assessment. You know—what services can we provide without access to 340B purchasing?

Can you say more about 340B drug pricing program, for people who might not know what it is or how it works?

ESSLINGER: So this is a program that we were eligible for based on our relationship with our local Planned Parenthood organization as a delegate of Title X funding. And so now that that that funding is gone, we no longer qualify for the discounted medications that we were receiving from there. So that would include all of our contraceptives and some of our STI treatment medications. Some of those costs have been rather small. Others jumped from like $1,000 to $5,000 more. So not only do those medications cost our program more money obviously, but that also means if we are being reimbursed by an insurance company or some sort of outside agency like a state insurance plan we’re also recuperating fewer costs that way as well.

That’s a hard financial hit.

KUOPPALA: We did the cost benefit on things we can purchase and we can recoup costs on, and the question of, you know, providing as comprehensive services as possible without you know running into huge debt. Then we just did an assessment of our patient flow, how many people were coming in and out of each site. We did an assessment of how many staff positions we could eliminate while still maintaining as many services to as many people as possible.

And so with that assessment we decided to eliminate half of our positions and started looking for other ways to maintain services—like partnerships and ways to get into another 340b partnership so we can get back on trip.

ESSLINGER: This is not the strategy that every small clinic has used because of their own circumstances, but by default of us being a community action agency it was really really, really, really important for us to figure out how to not increase costs for our patients.

Yeah, can we talk more about that? I can imagine it wasn’t an easy decision to make.

KUOPPALA: So I’ll say our staff is very mission driven and understood even though this was a painful decision for them and their families. I mean we discussed it with them and we tried to find other strategies and ideas, but in the end we’re here to serve our clients and they understood that.

How did you come to your decision about pulling out of the program? I know some clinics are staying in, so what felt like a nonstarter for you?

KUOPPALA: Being client focused means providing the very best service we can to our clients and not having a politician dictate exactly what sort of services we can provide. So being limited just in order to get a grant is just contrary to who we are and how we operate. We’d rather dig harder to figure out how to keep it going and hope that the politicians can sort it out on their end for whatever their purposes are. Family planning has been part of Community Action since we began in the 1960s. And then, just just earlier this year, the National Academy of Sciences Engineering and Medicine came out with their report on a roadmap to reducing child poverty. And so this was a group of professionals from across many different sectors who studied this for a couple of years and came out with this report—and family planning and Title X is one of their strategies. So when you ask how it feels, it’s just a little frustrating because it it kind of flies in the face of what we know works. And so that that’s difficult.

And we did focus groups with young people in our rural conservative counties to just see how they were learning about family planning, safe sex, and reproductive health overall. And they told us that they have trouble getting accurate information. So you know this is important—from the fear in people’s faces when they come in, or relief when they’re able to talk to someone who understands what their struggles are. You know it’s important.

ESSLINGER: That’s a really unique thing that we get to do in our clinics. We get to talk to young people about their hopes and dreams and the biggest concerns in their life right now. And how do you have these conversations with young people so that they feel affirmed in the decisions that they’re making and also so that they can think about the future? It no longer feels like we’re providing the same kind of intervention and prevention and education that we were able to before. And it’s just it’s hard to look at our communities and say, you know, we’ve been around for a really really long time and we’re going to try to be here for you as much as we can and also know that there’s going to be segments of the population that that we’re going to be missing because of this loss of funding.

So you’re in a position now where you’re operating with half the staff and facing higher costs for things like medication. Can you tell me a little about the day to day operations, and what feels different than it did maybe this time last year when the program was intact?

ESSLINGER: I would say it definitely feels a little chaotic right now, however that chaos I think is happening much more internally than it is externally to our patients. We’ve only had to cancel, I think, one clinic in the next month. Our providers and our staff have been really adaptable to this new normal. And so what we’re keeping our clinic doors open as much as possible.

But it has meant that we have four main locations and we now have two nurses who manage each one of those clinics. They’re driving all over the place every day to get to where our clients are. And it also means that when we are planning for the next week’s worth of clinics, we only keep enough stock now to anticipate what our clients’ [who have already booked appointments] needs might be. That’s the only stock that we have. Whereas before if someone said that they were interested in maybe being put on the NuvaRing and then they come in and they actually want an IUD, we would be able to accommodate that. Now we need to be a lot more careful and a lot more strategic in how we’re getting to our clients and giving them the services that they need because we just don’t have the same kind of capacity now. However we’re still trying to see the same, or a similar, number of patients at each one of our clinics.

KUOPPALA: It takes longer to return phone calls from patients. The staff we do have are busy running clinics during their hours. So it just takes longer to get back to folks. So there’s a little less convenience for people to just drop in for services. And then while we’re in this increased chaos, we’re trying to figure out how can we raise some money to pay for services. How do we communicate this? We’re nonpartisan and don’t want to get caught up in the politics of it, but [the rule change is] kind of political so you have to figure out how to have conversations in a way that are at a higher level than that. And encourage people to donate resources—you know, 10 bucks a month, just 20 bucks one time. These are very high poverty counties, though, so there’s not a lot of resources out there but we’re trying to shake the trees for what we can find.

I think one thing here, too, is the fact that the cost of healthcare is never just in the services themselves. It’s in the time you had to take off work, the bus fare, the gas you had to put in your car, the childcare you had to set up in advance. So there are these rippling costs that will only be made harder by a rollback in access or services.

KUOPPALA: We talked about how many of our patients come from over 10 miles away. We’re in very rural counties that have no real public transportation options. There is some transportation in the small towns—you know, so during the weekday you can catch a bus across town to go grocery shopping or something, but you can’t catch any bus or any kind of public transportation from outside of town. And so as we decrease hours and decrease flexibility for seeing patients, it really creates hardship. If someone had to hitchhike their way into town or catch a ride with someone to come in and get seen as a drop-ins—so to eliminate those services just creates a really, really big hardship in rural communities.

And one other example that comes to mind is just the personal empowerment that comes from having some kind of control over your own reproductive health. That same empowerment is the same kind of internal empowerment it takes to overcome other life challenges, you know? So I think living in fear every day of getting a sexually transmitted disease or getting pregnant when you’re not ready to or wondering what’s going on with you—that kind of fear. I think it also hits your self-esteem and the way you think about yourself and kind of gets in the way of other areas of life, too.

I know that your clinics, like a lot of clinics, are figuring out how to make due in the coming months, but do you have a sense of how this all works if the rule change holds? What does a one-year plan look like? A five-year plan?

KUOPPALA: Yeah, I guess we’re hopeful that that Congress will get this figured out if the courts don’t. So we’re cautiously optimistic that this will get sorted out. And meanwhile, while we’re in this period of chaos, we also have to do organizational planning to just figure out how can we sustain at a reduced level for a longer period of time. You know, it might take several years and we can’t operate in chaos that long. But this is very new. Right now, it’s chaotic. But I think what won’t change for us is just a commitment to helping people get out of poverty. We want to address the challenges that lead to deep and persistent poverty for them, and we’ll figure we’ll figure it out.

ESSLINGER: One thing I know about the communities that I work in is that we grow really resilient people here. And so I know that about my staff, I know that about the clients that we serve. And so I know that with that spirit, we’ll just keep moving forward and doing the best that we can and serving as many as possible.

But I think one of the things that’s been most important for me throughout this whole transition period and through all of this chaos is that we need to be talking to the people that we’re making these laws about—and especially getting the representation from our low-income communities, from our communities of color, from our LGBTQ communities to understand exactly what the fallout of these kinds of rules mean. And so I would just encourage folks to make sure that they are letting their voice be heard. Now’s the time to jump into action.