Dan Gorenstein: One year ago, the Supreme Court upended abortion access in the United States.

News clip: Breaking news from the Supreme Court at this hour, the justices handing down the highly anticipated ruling on abortion.
News clip: A ruling that overturned the landmark Roe v. Wade decision and ends the constitutional right to an abortion…

DG: In the last year, 15 states have effectively banned abortion. 

At least 29 clinics in those states have shut their doors. A few have moved into states where abortion is still legal.

But some have stayed put, facing down legal and financial risks to provide other health care services to their communities.

Leah Torres: There’s no place else for them to go. Quite literally, no place else for them to go.

DG: Today, we go to Alabama to learn what happens to a clinic and a community when an abortion clinic can no longer provide abortions.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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Alice Miranda Ollstein: I’m Alice Miranda Ollstein. I am a health care reporter for Politico.

DG: Last month, Alice published a story in Politico Magazine about the West Alabama Women’s Center. It’s an independent clinic that’s been providing abortion care in Tuscaloosa, Alabama, for 30 years.

In that time, the clinic’s been burned to the ground, shot at, driven into, had bomb threats. But it has always come back.

AMO: What was really striking to me is that while the battle used to be very sort of literal and easy to see — it was screaming protesters outside, it was attempts in the past to physically attack the clinic — now it’s all invisible. It’s funding threats, it’s legal threats. It’s things that they’re dealing with sort of behind the scenes, but that could still threaten their existence.

DG: So, Alice, let’s talk about some of those invisible threats. You mention funding. How has the clinic’s financial situation changed since it stopped providing abortion a year ago?

AMO: It really took going there in person to understand just how precarious their situation is. The vast majority of their revenue completely disappeared when abortion was outlawed. So they used to make around $150,000 to $200,000 a month from people paying out of pocket for abortions or in some limited cases, insurance reimbursements for abortions. That all ended. And so it’s down just to $2,000 a month. And so they are scrambling to apply for grants and just plead with folks for small dollar donations in order to float them.

DG: In your trip there, did you see how that pleading manifested itself in any way?

AMO: Well, I think that me being there in the first place was part of it. They see getting press coverage as key to their survival. So unlike a lot of clinics that are very wary of press, they were very welcoming. A lot of what they’re facing is that folks in the state have known them for three decades as just an abortion clinic, and people don’t know that they offer other services. And so I encountered patients who were students at the University of Alabama who were living just up the road and didn’t know that the clinic existed and didn’t know what they offered. 

DG: When you talk about patient revenue going from $150,000 to $200,000 a month down all the way to $2,000, I mean, that’s mind blowing. Do you have a sense how that shrinkage has changed the organization and how it operates?

AMO: So one of the first things they did after the Dobbs decision was they converted from a for-profit to a nonprofit. They also had to lay off half the staff, which really reduced the capacity of how many patients they could see. They are also looking into other cost saving measures. A big thing that eats up a lot of their funding is having to send out samples to private labs, you know, urine and blood samples, etcetera. And so they are looking at trying to buy second hand equipment to be able to do some of that work in house and save a lot of money. But they’re on the edge.

DG: What impact does this all have on patient care, Alice?

AMO: One thing that really struck me is that there are certain forms of contraception that they would love to stock that patients request and there’s really demand for, but they can’t afford to keep them in stock because of how extremely expensive they are. One example is a NuvaRing, which is a hormonal vaginal ring that somebody can put in and take out themselves. They don’t have to depend on the availability of a health care provider to do it like an IUD. But they can’t afford to stock them.

DG: So things sound pretty rough, Alice. I mean, patient revenues have dropped to just about nothing, they’ve had to lay off half of their staff, they can’t even afford some of the most basic products that their patients want. How is the West Alabama clinic staying open? Is it out of some sense of duty and obligation?

AMO: Absolutely. There just aren’t any health care providers at all in some of these communities, but especially not maternal health care providers. And so they were just afraid of what would happen to the people they serve if they were no longer there.

Robin Marty: Trans care, HIV care, preventative health care. 

AMO: I spoke a lot to the operations director of the clinic, Robin Marty.

RM: We need to be here because there is just as much lack of access for everything as there ever was for abortion.

AMO: Robin, she has sort of long gray hair and glasses. She’s very frazzled these days. She and Dr. Leah Torres, the clinic’s only remaining physician, they were dedicated to staying because they knew that people would still have abortions, whether by ordering pills and taking them at home or by traveling out of state and coming back. And they were afraid that if they closed their doors, people wouldn’t have anywhere where they could go in those circumstances.

DG: And you got a good look at the clinic offering this abortion-adjacent care first hand when you visited. Tell us about what you saw.

AMO: So there was an undocumented couple who came into the clinic who didn’t know that abortion was banned, which is apparently very common even a year later. They came in there expecting to be able to get an abortion that day. The clinic staff gently informed them that they couldn’t do that. But what they could do is have an ultrasound, see how far along in the pregnancy the woman was, and lay out her options. They found that she was well within the 10 week window where you can have a medication abortion, ordering pills, rather than having to have a procedure in another state. So they gave them information about where they can obtain them. And the couple was really relieved about that. And they told them, you know, if you have an issue, you can come back afterwards.

DG: And this couple did not want to talk to you, right? You saw them come in but had to get the details from the clinic staff. How difficult was it to get patients to talk to you? I’d guess that a lot of people probably wouldn’t want to talk to a reporter in that situation.

AMO: Yes, which is completely understandable. They’re there to get care. They are in a very vulnerable situation. You know, I wouldn’t talk to me either if I was in that circumstance. So I was very grateful that a few patients were willing to open up. One challenge is that the patients who were willing to talk were more privileged people. They were white, they had more resources. And that’s totally understandable why someone who’s in a more vulnerable place would be more scared to talk. But it was tough because most of the people that depend on the clinic are poor people of color. And so it was hard to capture that while also respecting people’s boundaries.

DG: When we come back, Alice talks about how the clinic is responding to the precarious legal landscape of the post-Dobbs world.

MIDROLL

DG: Welcome back. We’re here with Politico health care reporter Alice Miranda Ollstein who spent several days this spring at the West Alabama Women’s Center, a former abortion clinic in Tuscaloosa that has stayed open to provide non-abortion care. Alice, as you know, Alabama’s state attorney general has actually threatened to prosecute people who quote “aid and abet abortion.” Are the clinic staff worried at all about going to jail if they keep providing this care, especially helping people get abortions using pills or in other states?

AMO: So the attorney general has made some threats along those lines that what they do could be considered aiding and abetting. But they have consulted with lawyers and said that because they just direct patients to already public information about pills and other states to travel to, they feel that it’s protected by free speech. And so they are going ahead and doing it because they believe it’s important. They believe it’s important to patient care. Robin Marty, who runs things there, told me that they want to really sort of test the boundaries in this new era.

RM: If we don’t see where the edges are, we’re never going to be able to gain back any sort of ground for anyone. 

AMO: They say, look, if we are too scared and back down on this, you know, what’s next? What next will they say we aren’t able to talk about?

DG: Were you surprised that they struck that tone, that attitude? 

AMO: In some ways because a lot of bigger mainstream abortion rights groups have not sort of taken that attitude. They have taken a much more cautious attitude. We have seen people pull back on offering perfectly legal forms of care like emergency contraception in states with bans. So it was definitely sort of a more defiant tone than I’ve seen from others.

DG: So West Alabama is one of about 30 clinics that have stayed open in states with abortion bans to provide other care. You talked to some of these other clinics too. Were their stories pretty similar to West Alabama?

AMO: I found a lot of similarities, particularly in there being high demand for the sort of abortion adjacent services, the ultrasound before and the follow up after that. I talked to a clinic in Texas where that’s the majority of what they’re providing these days. The one difference I found is that some of these other red state clinics that are trying to hang on, they’re part of a multi state network and that gives them a little more security and stability. So, for instance, there’s a group called Trust Women that has clinics across Oklahoma and Kansas. Abortion is banned in Oklahoma. It’s still legal in Kansas. So the Kansas clinics in the same network are sort of able to subsidize the Oklahoma clinic so they can stay and keep providing other services. And West Alabama does not have that luxury.

DG: West Alabama really is an island unto itself.

AMO: Yes, it is. You know, even within the state, there was one independent abortion clinic in Montgomery that shut down, couldn’t hang on. One of the state’s two Planned Parenthood’s shut down, wasn’t able to hang on. So they’re really among a dying breed.

DG: You know, Alice, what you said at the beginning of our conversation has really stuck with me that this battle West Alabama and other clinics are fighting has changed from this very visible and physically dangerous one to more behind the scenes but maybe an even greater threat to their actual existence. 

AMO: Exactly. And whether these clinics survive or not really matters for lots of patients in areas where the state already has some of the worst rates in the country of maternal mortality, infant mortality, preterm birth, cervical cancer, teen pregnancy. There’s always a long lag on health care data. So it’s going to take a while for the true picture to really come into focus. But fewer providers and fewer clinics in a place where they are already really scarce. You know, it can’t be good. It can’t help.

DG: And perhaps what you just said is why Robin and the other staff members at West Alabama have struck such a defiant pose.

AMO: Yeah, they’re really afraid of just people dying, people dying if they’re not there for them. Dr. Leah Torres told me, look, this is just math.

LT: When you have more pregnant people, you’re going to have more pregnancy related deaths. Again, that’s math. Think of a bad pregnancy outcome and then make it worse, make it affect more people. And that is the post-Dobbs world.

AMO: And so they want to just do whatever they can to make the smallest amount of difference, even when it seems really insurmountable. You know, the clinic is dedicated to staying there in the hopes that the ban is someday lifted and abortion becomes legal again, as completely unthinkable as that may seem right now. They worry that if everyone leaves, there won’t be anyone left to provide abortions if and when they ever become legal again.

DG: Given all of the challenges that the clinic is facing with money, with the state, in your mind, what are the odds that the West Alabama Women’s Center is going to be around when the second anniversary of the Dobbs decision comes in 2024?

AMO: I have no idea because honestly it’s surprising that they’ve been able to hang on this long. But if they don’t get a big infusion from a grant or a foundation or just a bunch of small donors, then yes, they will not be able to survive.

DG: Alice Miranda Ollstein, thank you so much for taking the time to talk to us on Tradeoffs.

AMO: Thanks for having me.

DG: You can find a link to Alice’s Politico Magazine article on the West Alabama Women’s Center on our website, tradeoffs.org. I’m Dan Gorenstein, this is Tradeoffs.