Collateral contraceptives

A small brown paper bag in her hand, Julie walked out of a Planned Parenthood clinic in Roseville with a new supply of birth control. It didn’t matter that she didn’t have health insurance.

“It’s awesome to have Planned Parenthood,” said Julie, who did not wish to give her last name for privacy reasons. “To go to a regular health clinic like this would have cost $100, which would make you think twice about having to go.”

It’s the kind of clinic that President Donald Trump and conservative Republicans in Congress hope to cut off from receiving any federal funds. Already the federal government prohibits any federal dollars from paying for abortions except in cases of rape, incest or to save the mother’s life. But this effort seeks to block federal funds from paying for any other kind of health care by providers who also perform abortions.

If they succeed, the impact would be particularly strong in California—a state where legislators over the years have interpreted federal laws and rules in ways that have allowed more federal dollars to flow to Planned Parenthood clinics. Roughly half of the federal funding that Planned Parenthood receives nationwide now goes, mostly via Medicaid reimbursements, to cover health care and family planning services for mostly low-income Californians.

And ironically, Planned Parenthood officials say if they were to lose all their federal funding, their California abortion clinics would remain open—those already are funded by private sources and by state reimbursements for poorer patients. Instead, what would be at risk are all the nonsurgical sites that provide other medical and contraception services.

The state’s progressive state policies, put in place 30 years ago under Republican Gov. Pete Wilson, created a friendly environment for Planned Parenthood to expand and offer family planning services to low-income men and women above the federal poverty level. That’s in stark contrast to states such as Texas and Mississippi, which unsuccessfully sought to ban their state Medicaid health care programs for the poor from channeling any money to health care providers that perform abortions.

As a result, today Planned Parenthood is one of California’s major health care providers, operating 115 clinics that serve 850,000 mostly low-income patients a year who rely on Medicaid (in California, Medi-Cal) for health care. That’s nearly a third of the 2.5 million patients who visit Planned Parenthood clinics nationwide for basic health care and family planning services.

“Planned Parenthood is a major safety-net provider at a time of increased health care demand,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. “In a state like California with more Planned Parenthoods, the reliance would be that much greater.”

The Republican-controlled Congress, bolstered by Trump’s election, is eyeing several strategies to stop the flow of federal funding to Planned Parenthood. That money—roughly $500 million a year nationwide, through Medicaid reimbursements, Title X family planning money and grants—pays for services such as cancer screening, breast exams, birth control, prenatal care and treating sexually transmitted diseases.

Although Trump has frequently acknowledged that Planned Parenthood helps millions of women, he also has said he would support congressional efforts to ban funding.

“I would defund it because of the abortion factor,” he said at the February 2016 GOP presidential debate. “I would defund it, because I’m pro-life.”

A draft House GOP bill obtained by Politico would eliminate all federal funding to Planned Parenthood as part of a repeal of the Affordable Care Act. While that provision is likely to clear the House, its fate is uncertain in the Senate, where several moderate Republicans could side with pro-choice Democrats.

But if the effort were to prevail, California Planned Parenthood would lose $260 million a year in federal funds—approximately 80 percent of its operating budget. Unless it found a way to replenish that money elsewhere, the organization warns that it might have to close its 82 California sites furnishing basic health care and family planning services to mostly low-income patients.

Meanwhile, its remaining 33 surgical abortion sites—which don’t get federal funding—would remain open, said Kathy Kneer, president and CEO of California Planned Parenthood.

“The irony here is that they are going to put in place more barriers for women to gain contraception, and that will lead to more abortions—and by the way, all the abortion sites will stay open,” Kneer said.

Last month the House voted to reverse an Obama administration regulation that requires states and local governments to distribute family planning funds to health centers even if they perform abortions. President Barack Obama issued the rule in his final days in office after more than a dozen conservative states directed those funds only to community health care centers.

Such an 11th-hour move by an outgoing president, Republicans argued during the floor debate, was an affront to states’ rights.

“I know that vulnerable women seeking true comprehensive care deserve better than abortion-centric facilities like Planned Parenthood,” said Rep. Diane Black, R-Tennessee.

The resolution is now awaiting a vote in the Senate where California Democratic Sen. Dianne Feinstein is working to defeat it. It would have no effect on California, given that it is not among the states that have tried to limit those Title X dollars. Nonetheless, she noted that Planned Parenthood provides the only Title X family planning services in 13 California counties, and that any effort to strip federal funding would take a toll in other states and leave “huge numbers of women across the country [with] no place to go for essential health services.”

Trump on the campaign trail vowed to defund Planned Parenthood. He then appointed Secretary of Health and Human Services Tom Price, a former Republican congressman from Georgia who has supported cutting off taxpayer money to Planned Parenthood.

Both men have suggested the federal government could reallocate taxpayer dollars to community health centers. But many experts and health care advocates say those health centers cannot absorb the significant number of patients who now rely on Planned Parenthood.

“Any policies that eliminate or diminish Planned Parenthood’s role would put untenable stress on remaining health centers,” said Ben Avey, spokesman for CaliforniaHealth + Advocates, which represents the state’s community clinics and health centers. “They are really a vital part of the state’s health network.”

That concern was echoed in January when the Democratic-controlled California Legislature approved resolutions opposing any congressional efforts to defund Planned Parenthood. They did so after Planned Parenthood President Cecile Richards met with Democratic senators at their annual policy retreat in Sacramento.

Assembly Speaker Anthony Rendon, D-Lakewood, proclaimed: “California stands with Planned Parenthood because Planned Parenthood stands with California.”

But his sentiment was not unanimous. Several Republicans spoke out against the resolutions, with state Sen. Mike Morrell, R-Rancho Cucamonga, saying he could not support an organization that provides abortions.

“I have no war against women,” he said. “But I also do not have a war against babies created in the image of God.”

With a Democrat-controlled state Legislature, California Planned Parenthood is hopeful it could ask lawmakers to backfill any federal shortfall. However, Medicaid funding is already strapped in the state, where a record one in three Californians are receiving Medi-Cal. Given the potential for other federal cuts in health funding that the state might also be asked to compensate for, it’s unclear whether the state would be able to make up the difference.

So Planned Parenthood is drafting contingency plans.

“We are looking at scenario planning. These are all very difficult decisions,” Kneer said. “Closing any location is the last thing we want to do.”

One option is to more aggressively fundraise, but Kneer said private donations can’t possibly make up what they would lose. She also raised the question of whether private funds should be required to pay for a government reimbursement that other organizations receive.

Even if Trump receives and signs legislation to strip Planned Parenthood of all its federal funding, Planned Parenthood could still challenge in court whether such a restriction is constitutional.

In the last few years, federal courts across the country have denied other states’ efforts to block Planned Parenthood as an eligible provider of taxpayer-funded health, ruling that such moves violated the First Amendment right of free speech and free association to choose a medical provider, and the right of a clinic to provide abortion services under the equal protection clause of the 14th Amendment, said Julie Cantor, an adjunct professor at UCLA who teaches a law class on reproductive medical ethics.

“The government’s behavior has to comport with the Constitution,” Cantor said.