When most Americans think of abortion, they think of Planned Parenthood. Its visibility and national infrastructure make it a target for destruction or defunding, but also for support: Since Election Day, Planned Parenthood has received more than 260,000 donations.
In reality, though, 60 to 80 percent of abortions in the United States are performed by independent providers, according to the most recent data from the Guttmacher Institute. Those providers potentially face just as difficult a road ahead under a Trump administration, but often get skipped over for donations since they don’t have the brand recognition of Planned Parenthood.
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Planned Parenthood affiliates and independent clinics suffer alike from general restrictions on abortion—independent clinics arguably more so, because many of them lack the large infrastructure that Planned Parenthood provides its local affiliates. But if direct attacks on Planned Parenthood were ever to curtail its operations, independent clinics would be left to fill in the gaps.
“That would make it harder on people seeking abortions. They might have to travel farther, or spend more money, and it would be a huge strain on organizations that don’t have the same kind of support,” said Jennifer Thibodeau of Abortion Care Network, an association of independent providers founded in 2008. “It’s really necessary that every clinic that’s open stay open. Defending Planned Parenthood is important, and so is realizing that two-thirds of abortions are performed by independent providers. Without those clinics, there really is no meaningful access to abortion.”
Organizational structures of independent providers vary widely from individual doctors, to small local clinics, to multi-state chains. They also vary in terms of the services and procedures on offer: Some provide only abortion and family-planning services, while others also provide STI testing, cancer screenings, general healthcare, and trans health care. Some offer an even broader spectrum of care, including full prenatal services, which are not available at most Planned Parenthood affiliates.
Some “indies” are nonprofits, but even those with a for-profit model aren’t making much money. Targeted regulation of abortion provider (TRAP) laws—the blanket term for laws that impose medically unnecessary requirements on abortion clinics—have made them more expensive to operate than ever before. Clinics tend to serve large numbers of uninsured or underinsured patients, and even those with private insurance are often without abortion coverage. Many clinics reduce the cost of services for people who can’t afford them. Even when a patient is insured, some private insurance companies choose not to cover abortion, and some states—like North Dakota—prohibit all private insurance coverage of abortion.
In 2014, 31 percent of abortion patients had private insurance, but 61 percent of those with insurance had to pay out of pocket for the procedure. Thirty-five percent were enrolled in Medicaid, but because the Hyde amendment prevents federal funds from being used to cover abortion in most cases, Medicaid only covers abortions in the 17 states that have chosen to pay for it themselves.
“Many independent clinics sprung up in the early days after Roe v. Wade. It was about women helping women, wanting to provide abortion services and take them out of the hospital setting, make it more independent, more personal,” Tammi Kromenaker, director of Red River Women’s Clinic in Fargo, North Dakota, told me.
Red River is the only abortion provider in North Dakota and also serves parts of South Dakota and northwestern Minnesota. (There are no Planned Parenthoods in North Dakota.) North Dakota is among the states with the tightest abortion restrictions in the country—a 24-hour waiting period, consent of both parents for minors, a rule that only physicians can perform abortions (when the procedures can be just as safely performed by nurse practitioners, certified nurse midwives, and physician assistants), state-mandated counseling that discourages abortion, a law that requires doctors to have admitting privileges at nearby hospitals, a ban on abortion after 20 weeks, and more. In 2013, the state made national headlines by enacting a ban on abortions after six weeks, the most restrictive abortion law passed since Roe v. Wade. The law was later overturned by a federal court, but was exactly the kind of direct challenge to Roe that many expect under a Donald Trump presidency.
“Many of our providers are working in the most hostile states politically, dealing with constant challenges, whether those are legislative or come from protesters,” Thibodeau told me.
After aggressive abortion restrictions passed in North Dakota in 2007, 2009, 2011, and 2013 (the state legislature meets only every other year), Red River got a reprieve in 2015, when no new abortion restrictions were introduced. Kromenaker credits this to the fact that North Dakota’s two most vocal anti-abortion legislators had lost reelection campaigns in 2014 and were replaced by pro-choice officials. A 2014 ballot measure that would have granted fetuses legal personhood also failed dramatically, by a margin of 64 percent to 36 percent.
“We had been considering some proactive legislation, but after the election results, both locally and nationally, that’s clearly not going to happen. We lost some important allies in the legislature,” said Kromenaker. She expects that the 2017 legislative session will bring new restrictions that Red River will have to fight in court.
“Without those clinics, there really is no meaningful access to abortion.” — Jennifer Thibodeau
Kim Chiz, executive director of Allentown Women’s Center in Bethlehem, Pennsylvania, says that her clinic used to sell birth-control pills at a low cash price to make them more accessible. “We hardly sell them anymore because so many people now have contraceptive coverage. Going forward, I expect we might see a greater need to offer contraceptives if that contraceptive mandate is changed,” she told me.
Patients will rely on independent clinics for more than birth control if changes to the Affordable Care Act—which Donald Trump has promised to repeal—cause them to lose health insurance. “Reproductive health clinics provide the only care that some women get all year,” said Thibodeau.
Pennsylvania’s current governor, Democrat Tom Wolf, has said he will veto any legislation further limiting abortion access in Pennsylvania. But there is still a chance that legislators could override his veto. This year, Pennsylvania lawmakers have considered a bill that would ban abortion after 20 weeks. Abortion is currently legal in Pennsylvania up until 24 weeks.
“We have a pregnancy-loss program here, and many patients in that program have a wanted pregnancy, but don’t find out until 17 to 19 weeks that their fetus has a severe abnormality. We typically see them between 18 and 22 weeks,” Chiz told me. “That decision should not be legislated. It should be between them and their healthcare provider.”
As for all abortion providers, safety is a primary concern. “One of our doctors has a protester who shows up at his house once a week. We have protesters here almost daily, and a handful that are really difficult. They make racist, homophobic, and transphobic comments to my staff, and comments about people’s weight. They even impersonate our escorts,” said Chiz, describing one protester who wears a vest similar to those of the clinic escorts and waits in the parking lot with a clipboard.
Chiz and Kromenaker have both seen an increase in interest from volunteers since the election, though they have also encountered some confusion regarding the fact that they are not Planned Parenthood affiliates. While clinics that follow a for-profit model do not accept donations, they do work with local abortion funds to help patients who cannot afford their procedures. They also rely on volunteers to be clinic escorts and to help with community outreach work.
“Sometimes protesters yell at me, ‘Go get a real job! Go somewhere where you can help people!” said Chiz. “Well, there’s no more profound way I could help people. This is as real as life gets.”
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