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Planned Parenthood has been controversial since its 1916 founding, but the latest wave of political battles against it began in earnest in 2007, when then-Rep. Mike Pence introduced an amendment to a House of Representatives’ appropriations bill to block federal funds from going to the organization’s nationwide network of reproductive health clinics.
Planned Parenthood was targeted because it’s the largest abortion provider in the United States, but it wasn’t its abortion services that were on the chopping block. Federal law already prohibits federal funds from being used for abortion services. Instead, the bill would have ended payments to Planned Parenthood for other health services, like cancer screenings, testing for sexually transmitted infections, regular reproductive health exams and contraception.
The goal of Republican pro-life lawmakers like Pence has long been to put abortion clinics out of business. But what the long-running fight against Planned Parenthood and other abortion providers shows is that access to abortion and birth control are often linked. In fact, almost all clinics that provide abortion services also provide contraceptive services.
In many states, anti-abortion politics can limit patients’ access to contraception, especially low-income women who rely on publicly funded clinics. That could be even more true as some abortion clinics around the country start to close following the Supreme Court’s ruling last month overturning the constitutional right to abortion. For many people worried about an unplanned pregnancy, all of the tools that they might use to prevent one — from birth control to abortion — are out of reach simply because of where they live.
“My biggest fear right now is the fact that, as we are heading into this post-Roe phase, is that red states — and especially red Southern states — where there are already so few Planned Parenthoods, are going to lose them and as those are in essence, the same place that people can even get contraception, it’s going to make all of this so much more dire,” said Robin Marty, director of operations for the West Alabama Women’s Center.
Planned Parenthood clinics are an important part of the reproductive health landscape. Currently, many low-income patients without private insurance access birth control through Medicaid or Title X, the latter of which funds clinics that provide birth control and other family-planning services. According to Planned Parenthood, in 2018 nearly half of its patients received Medicaid, and according to the Kaiser Family Foundation, Planned Parenthood in 2019 served 32 percent of the patients who sought contraceptives at safety-net clinics.
But more than that, Planned Parenthood and other clinics that offer abortions are often exclusively focused on reproductive care, which means patients can sometimes obtain contraception faster and have a wider range of options than other places, like Federally Qualified Health Centers or through county health departments, that see other patients for needs beyond just reproductive health care.
Marty said, for instance, that in Alabama, most Title X funds are distributed through county health departments and there is often only one department per county, regardless of the population relying on that clinic for services. “Because of that, most people are waiting three months, four months in order to be able to get in for birth control,” she said. “I’ve been in Alabama for a little over a year now, and one of the things that has utterly blown me away is how little birth control access already exists in the state and in the South,” she said.
And some states have already moved to further restrict access to these services. At least four states — Arkansas, Texas, Mississippi and Missouri — have attempted to block Planned Parenthood from receiving Medicaid funds. These bans have been challenged in court, but so far federal judges have allowed the Arkansas and Texas bans to stand. Karen Stone, vice president of public policy and government relations at Planned Parenthood Federation of America, said in a statement that Planned Parenthood is “urging the administration to enforce” a provision that says Medicaid recipients should be able to choose their own providers. “Right now, a number of the states that have or are attempting to ban abortion have also cut off Medicaid patients’ access to preventive care,” the statement said.
Even more fundamental, though, 12 states have not expanded Medicaid under the Affordable Care Act at all. And without Medicaid expansion, uninsured rates remain higher in these states than the rest of the nation, which means patients who want access to contraception don’t have the care that Medicaid guarantees. And as you can see in the map below, there’s a lot of overlap between the states that haven’t expanded Medicaid and those that have or plan to limit access to abortion.
That said, even in states where Medicaid has been expanded but abortion is banned or limited within a few weeks of conception, there are other barriers to receiving contraceptive care. A particular point of contention is emergency contraception, which doesn’t end a pregnancy but has come under fire from legislators who believe it might prevent a fertilized egg from implanting in the uterus. (Studies have shown it works primarily by preventing ovulation.) “I think that has opened the door for politicians, particularly in these more hostile states to … think about using language that that exists in anti-abortion bills” to limit access to birth control, said Megan Kavanaugh, a principal research scientist at the Guttmacher Institute, a research organization that supports abortion rights.
Fifteen states and Washington, D.C., currently require emergency rooms to dispense emergency contraception on request, but many of those states have not restricted abortion rights since the Supreme Court decision, according to the Guttmacher Institute. (Additionally, Arkansas, Colorado, Virginia and Texas require emergency rooms to provide information about emergency contraception, while Ohio and Pennsylvania require emergency rooms to dispense emergency contraception but lack an enforcement mechanism or allow providers to opt out.) Thirteen other states allow doctors, hospitals, pharmacists and/or employers to refuse to administer or prescribe emergency contraception. And many of these states that allow providers to opt out of providing emergency contraception are also now banning abortion, or limiting it to very early in pregnancy.
The Title X program is supposed to provide a backstop for uninsured patients to still have access to birth control, but how those funds are distributed and used is often political. For instance, in 2019, the Trump administration instituted a rule that clinics that provide or refer patients to abortion services couldn’t receive Title X funds, effectively blocking Planned Parenthood and other abortion clinics from receiving money from the program. Providers referred to it as a “gag” rule, and Planned Parenthood pulled out of some states where they had been providing Title X-funded services because they refused to comply with the ban. (Six states — Hawaii, Maine, Oregon, Vermont, Utah and Washington — saw all of their Title X clinics pull out of the program.)
In fact, in the following years, 2.4 million fewer patients were served by Title X clinics, according to an analysis from the federal Office of Population Affairs. While some of that was due to the COVID-19 pandemic, the OPA found that about two-thirds of the loss in clients was attributable to the Trump rules, versus about a third to the pandemic. The Biden administration reversed those rules in 2021, but that only recently went into effect, and service levels haven’t bounced back. Funding for the program has thus far remained relatively stagnant, too.
Even before 2019, though, access to Title X services depended on where patients lived. In a 2021 study, political scientists Candis Watts Smith, Rebecca Kreitzer, Kellen Kane and Tracee Saunders examined patient access to Planned Parenthood clinics in the Title X network located within a reasonable distance.
Although the 10 states they studied distributed Title X funds in a variety of ways, overall, between 17 and 53 percent of reproductive-age residents lived in a contraception desert, meaning the nearest clinics were beyond what they classified a reasonable traveling distance. Moreover, low-income people and people of color were disproportionately likely to live in a contraception desert, and they found that this problem would be made worse if Planned Parenthood were blocked from the program entirely.
In fact, patients seeking abortions are already likely driving longer distances to receive care, further straining a system that also provides contraception care. “The health care centers located in what we’re calling surge states are going to necessarily need to be able to provide and meet these patients’ needs for abortion care, and that could very well impact their capacity to provide the other range of sexual reproductive health care needs that our patients have,” Kavanaugh said. They may need to focus on abortion care at the expense of other services in some instances, she said.
That’s why as abortion clinics continue to close, an already strained system will now have to absorb all of the reproductive health care needs that will go unaddressed, especially if more pregnancies continue because of a lack of access to birth control and abortion. “Right now it’s important, it’s really important, to make sure that our family planning network is robust and well-funded across the country,” said Alina Salganicoff, director of women’s health policy at the Kaiser Family Foundation. “Particularly in places where abortion will no longer be available.”
