A renewed focus on protecting access to birth control may not help women who are already struggling to find affordable contraception in some states with the strictest abortion laws.
At a family planning clinic in Tuscaloosa, Alabama, that largely helps low-income women, executive director Robin Marty has to make sure the clinic, WAWC Healthcare, has a variety of contraceptives on hand, including pills , patches, implants and IUDs, so patients can get free or low-cost birth control during their appointments.
That’s something that has become increasingly difficult to do in Alabama, along with other southern rural states including Mississippi and Texas.
“Most of our clients are people who are at or below the poverty line. Most of them are black women, and many of them do not have a primary care provider. They come to us to access the contraception,” Marty said.
Years before the Supreme Court’s Dobbs decision overturned Roe v. Wade, political changes, flatlined financing and lock clinics puts a strain on small family planning providers who have to finance the initial cost of providing a range of contraceptives, from birth control pills to injections to intrauterine devices, for their patients. That can reach about $30,000 for a clinic that dispenses birth control to about 50 to 75 patients a month, said Kate McCollum, senior director of the Trust Her initiative at the Child Poverty Action Lab in Dallas.
Federal regulations require states to cover contraception for Medicaid recipients, but states can decide which types are covered. It can also be difficult to qualify. For example, in Mississippi, a single woman who is not pregnant cannot make more than about $20,000 before taxes to qualify for Medicaid.
Having birth control on hand is important. If a clinic doesn’t provide a person’s preferred method of contraception, they often won’t return, McCollum said.
“We see that especially for people who have a low income, finding childcare, transportation, leaving work is not feasible,” he said.
Few community clinics have the amount of money needed to cover birth control each month, McCollum said. Even if they do, “take a risk by firing them because you might not be paid back.”
The closing of the clinics puts pressure on those that remain
There was hope that when the Food and Drug Administration approved the first birth control pill for sale in 2023, the cost of $20 a month would help. Opill is stocked in stores nationwide, including select Target locations, Walmart, Walgreens and CVS.
But over-the-counter birth control pills have not reached many women in rural areas. “They’re often lucky if they have a grocery store in their town,” Marty said.
In such rural areas, residents “don’t have broadband, mail delivery doesn’t always show up,” Marty said. “I can’t stress enough how important it is to have everything in one person’s hands during a face-to-face meeting.”
In Mississippi, it’s common for women seeking a clinic to travel two hours for an appointment, said Jitoria Hunter, vice president of external affairs for Converge, a nonprofit that awards federal funding for family planning services in Mississippi. and Tennessee.
The last one report by the Center for Healthcare Quality and Payment Reform, a non-profit organization that advocates for improvements in healthcare payment and delivery systems, found that more than 40% of hospitals in Alabama, Mississippi and Texas, as well as neighboring Louisiana, Arkansas and Oklahoma are at risk of closing due to financial strain, adding to the shortage of family planning care.
In many cases, these closures are the result of policy changes that have eliminated a very important source of funding: Title X family planning grants.
Title X play a major role in funding family planning services for women living near or at the federal poverty level, including birth control and preventive health services like Pap smears. Each state decides which clinics receive this funding. In 2011, in an effort to divert funds from Planned Parenthood, Texas lawmakers voted to exclude any clinic associated with an abortion provider from Title X grants. This meant that even if a clinic did not perform abortions, if it was associated with one that did, such as a Planned Parenthood in another state, could not receive the funding.
Because of the Texas policy change estimated a quarter of family planning clinics in the state have closed since 2013.
In Texas, “Title X clinics have had flat funding for years. It’s not enough to meet demand,” McCollum said.
In Mississippi, the state with the highest teenager and premature birth rates and the the second highest maternal mortality rate in the nation, “the grant of Title X is not enough to cover the intake of those patients since the hospitals have closed or are significantly in the red with seeing patients,” Hunter said.
Even with deep discounts provided by the federal 340B subsidized drug pricing program, clinics charge tens of thousands of dollars for birth control without a Medicaid guarantee, insurance or cash reimbursement. Private insurers may not cover it either IUDs, which can cost as much as $1,300, according to Planned Parenthood.
“If we have a patient who comes in on Medicaid and they want to get a Nexplanon implant, we have two options,” Marty said.
The first is to buy the device, a small stick implanted under the skin which slowly releases the hormone over three years, at the full price of about $1,200, which Medicaid is not always reimbursed, and may not reimburse at all. Alabama, Texas and Mississippi are among 10 states that voted not to expand Medicaid this year, meaning it remains difficult to qualify.
The second option is to get the implant through the 340B program, which Marty said costs about $500. Even with that discount, many of his low-income patients can’t afford it.
“So anyway, we’re out of money,” Marty said.
When government programs fall short, a handful of non-profit organizations have stepped in to help clinics provide free or low-cost contraceptives. In Texas, the Trust Her initiative subsidized 20 clinics in Dallas County with grants to cover a month’s supply of birth control.
“If someone doesn’t have insurance, we can pay for their visit and their birth control method,” McCollum said. “If they have Medicaid or private insurance, they can draw from that stock when the patient is there and then be reimbursed.”
The non-profit group funded it Comadre Telemedicine in Dallas, which covers the cost of patient visits and birth control. Micaela Sanchez, women’s health nurse and founder of the Dallas clinic, became a parent at 17 years old, so the mission of stocking any type of birth control that someone may want is personal to her.
Because it is not a Title X clinic, Sanchez can advise minors about contraceptives with writing parental permission, but it also means that he does not have access to that source of funding.
“The reason I can do this is because Trust Her covers the cost of patients who get same-day options,” Sanchez said.
Plan A, a free community clinic in Louise, Mississippi, which also operates a mobile clinic in the Mississippi Delta and an upcoming clinic in Georgia, is able to provide all forms of birth control only through donations – of supplies and money – from other organizations.
Meta Anderson, a nurse practitioner at Plan A, recently placed an order for Nexplanon for a patient in her late 20s who works as a hair stylist and has no health insurance. She came to Plan A after being unable to obtain the contraceptive implant through her primary care physician. The provider, a federally qualified health center, charges patients a tiered fee.
“They’re going to have to pay a fee to be seen, and then they’re going to have to pay for the implant,” Anderson said. “He doesn’t have the funds to pay for it out of pocket.”
CORRECTION: (August 3, 12:18 pm ET): A previous version of this article misstated the terms by which Comadre Telemedicine can advise minors on birth control. The clinic needs the written permission of the parents, and cannot do without it. The article also misstated the availability of free contraceptives at Plan A. The clinic is able to provide all forms of birth control through donations, and there is no lack of supply.
