Independent Abortion Clinics Are The Backbone of Reproductive Care in America

Ashley was pregnant and lived about an hour outside Wichita, Kansas. Workers at Trust Women in Kansas had gotten her as much funding for her abortion as possible, but she’d still have to shell out a couple hundred dollars herself. She kept cancelling appointments, and Rebecca Tong, now co-executive director of Trust Women in Oklahoma and Kansas, kept rescheduling her.

“We got to the very end of when we could see her, and I told her, ‘If we don’t see you at this appointment, we will not be able to see you at all, because of the arbitrary limits set in Kansas of 20 weeks,’” Tong told Jezebel.

Ashley never showed up for that appointment.

Her son had a condition that required a lot of hospital visits, and his care took priority. When Ashley missed that last appointment, Tong tried to reach her again. “I called her back after she had missed that last appointment, just to see how she was doing, and her phone had been shut off,” she told Jezebel. For abortion providers — from the clinicians to the support staff to escorts — there’s always at least one patient who sticks in your mind. For Tong, it’s Ashley. “We try to provide as much help as possible, but it won’t be enough for everyone,” she said.

2021 has been the one of the most hostile years toward abortion rights in history. State legislatures enacted more than 100 anti-abortion laws this year; Texas passed cruel Senate Bill 8, banning abortion after six weeks in the country’s second largest state and deputizing citizens to spy on and sue each other— causing a wave of patients to spill across the country; multiple states have eagerly followed in the path carved by the Texas Republicans; oh, and the Supreme Court has been asked to decide if the right to abortion granted in Roe v. Wade is constitutional. Through it all, independent abortion clinics have kept going, as politicians continue to press their foot into the providers’ proverbial necks.

The state of independent abortion clinics is both dire and uplifting. Tong’s Trust Women is one of hundreds of clinics surveyed as a part of fifth annual Abortion Care Network’s (ACN) Communities Need Clinics 2021 report on the state of independent abortion providers in America released Tuesday. Independent clinics are the foundation of abortion provision in America, but most people wouldn’t know it. Fifty-eight percent of abortions in the country are performed at independent clinics, which also operate the most clinics in the states most hostile to reproductive choice without the backing of a name brand institution like Planned Parenthood. In four states, independent abortion care providers are the only clinic still standing after decades of targeted restrictions on abortion providers (TRAP laws).

As an independent abortion clinic goes to the Supreme Court to defend everyone’s right to abortion, understanding the landscape of these health centers could not be more critical. “This is a really important clarion call about the state of reproductive health in our country,” ACN Deputy Director Erin Grant told Jezebel.

Where Americans Get Abortions

Republican politicians and weirdo anti-abortion operatives tried their absolute best to make Planned Parenthood the face of abortion providers at the tail-end of the Obama administration. Republicans even brought their former president, the poised Cecile Richards, up to Congress to answer for unfounded accusations against the then-nearly 100-year-old reproductive health nonprofit organization. Despite all this work, anti-abortion politicians and activists went after the wrong target. Planned Parenthood is not where most Americans get abortions: Fifty-eight percent of abortions (medical or surgical) are provided by independent abortion clinics, compared to 37 percent at Planned Parenthood health centers and 3 percent at hospitals, according to the new report from ACN.

Independent clinics not only provide the most abortions to Americans, but provide the most abortion care throughout pregnancy, according to ACN’s latest report. Independent clinics are 64 percent of clinics that provide abortion care at or after 16 weeks. And if you need abortion care after 26 weeks of pregnancy? 100 percent of your options will be independent abortion clinics.

Continued access to abortion care requires independent clinics stay open, especially as they’re often the only option left in the state. In Mississippi, North Dakota, West Virginia and Wyoming, independent clinics are all that’s left. In Louisiana, there are three clinics still open, but they’re all independent clinics. If you live in Arkansas, Nevada or Georgia and need a surgical abortion (sometimes referred to as an in-clinic abortion), the only places providing that procedure are independent clinics. Besides being taken care of by independent abortion providers, what else do those states have in common? Hostility to abortion.

Women’s Health Center of West Virginia is the last abortion clinic in West Virginia. Katie Quinonez, the executive director, said being the only clinic means they have other responsibilities outside of providing healthcare to the roughly 3,000 annual patients. “It feels like it’s on us to hold the line and hold onto the access we have by showing up and fighting these legal battles,” she told Jezebel. “The last fight that we had to get involved with was back in 2020 at the very beginning of the pandemic.”

On March 31, 2020, West Virginia Gov. Jim Justice signed an executive order banning elective procedures not medically necessary, and the state attorney general said abortions qualified. It left WHCWV hobbled for a month. WHCWV brought litigation. “It was really, really hard because we only provided abortion care to a third of the patients that we normally would. And then, of course, when we finally were able to get the executive order lifted, we not only had to take care of patients that would have regularly been coming to us anyway, but all the patients who had to wait for that month. So we were very busy last spring.”

No Name Recognition? More Problems

Arguably the most well known independent abortion clinic in America is Whole Woman’s Health. The clinic was made famous by Whole Woman’s Health v. Hellerstedt, the 2016 landmark Supreme Court case overturning unnecessary TRAP laws. But it had been in operation since 2003 and served not only Texas, but patients in Maryland, Virginia, and Indiana as well as virtual appointments in New Mexico, Minnesota and Virginia. Founder Amy Hagstrom Miller worked for independent providers, local doctors, big organizations like Planned Parenthood before buying her first clinic. Abortion clinics, dating back to the 70s, were set up like any other medical office, usually as LLCs. “For years and years and years, you could run a clinic that provides abortion off of the receipts from insurance, Medicaid and self-pay patients, just like any other medical practice,” Hagstrom Miller told me. “Then all of the targeted regulation around abortions in this country made it harder and harder and harder for us to run sustainable practices with all of that political and regulatory interference.”

Medically unnecessary regulatory interference would make it hard to run any type of healthcare office — dermatology, oncology, pediatrics — not just reproductive. But when the politics come into play, the set-up of independent abortion clinics becomes a problem with no solution. The law is clear on what type of business designations can and cannot receive donations and grants. “Yes, I have name recognition, and it was really the direct result of our Supreme Court case [in 2016]. All of a sudden, people started knowing Whole Woman’s Health, knowing our name, but I didn’t have a way to receive that support,” she told Jezebel. “I’m talking like billions of hits to our website, and we had no idea what to do with it.”

In 2015, Hagstrom Miller set up the nonprofit organization Whole Woman’s Health Alliance in direct response to Texas House Bill 2, which would go on to shut down half the abortion clinics in Texas. “I just hit this point of [realizing] I can’t keep these doors open sustainably without figuring out how to receive grant money, donation money, support from the foundations. Because I looked over at Planned Parenthood, who has a system of fundraising every time a bad law is passed, while we’re closing our clinics,” she told Jezebel. “I was getting so mad, and everybody in the independent provider world just gets mad about it. And then I’m like, You know what? Instead of being mad, I’m going to figure out how to do the same thing.”

“It should be possible for us to run a sustainable medical practice. Abortion is health care, right? But we’ve been pushed out of the mainstream of health care. More and more, we can’t accept insurance and Medicaid. The overhead is just astronomical to comply with some of the regulations, and it didn’t used to be that way a decade or two ago,” Hagstrom Miller said.

The overhead, unsustainable economics and continued political attacks can spell the end for independent abortion clinics. The number of independent abortion clinics has declined by 30 percent since ACN started tracking clinic closures in 2012. There were 510 operating clinics when the network started its count; today there are 358 open. Since 2016, 113 independent clinics have closed.

Unrelenting Legal Attacks

Like all reproductive rights organizations, independent clinics are under unrelenting legal maneuvers from anti-abortion legislatures and activists who want to see abortion outlawed. “Bodily autonomy bans are clogging our democratic system,” Grant told Jezebel, perhaps understating the issue. This year, more than 100 anti-abortion policies were enacted at the state level and some legislatures are still in session. Texas SB8 has sent abortion providers reeling by the influx of patients fleeing Texas and pushing residents of those neighboring states to other states.

Democrats, despite holding a very tenuous grip on power, have not made federal advancement to help abortion providers and their patients. Pro-abortion activists point to the Women’s Health Protection Act as a starting point despite the name, but the House-passed law appears to be dead in the Senate without filibuster reform. Democratic lawmakers seem uninterested in repealing private insurance bans on abortion coverage or permanently banning the Hyde and Helms amendments. “We are not able to actualize policies that protect and ensure health care in this country,” they told Jezebel.

Until then, independent abortion clinics will continue to provide the majority of abortion care in this country. But as Grant said: “Abortion providers do not need to be martyrs nor superheroes.”