Lindsay Goldner knew one thing for sure after the election: She needed to go to Planned Parenthood ASAP. A few months before Donald Trump's win, the 28-year-old brand designer had enrolled in her state's Medicaid program, but she hadn't yet found an OB-GYN that accepted government insurance.
"I've had issues when it comes to finding a gynecologist," Goldner, who lives in Portland, Oregon, said in an email to Mic. "Sometimes they're not taking new patients — particularly with Medicaid involved [because] there's usually a cap — so you end up either having to wait months to see someone or settling for whoever you can find, which isn't ideal."
In the face of Trump's impending inauguration, Goldner didn't feel she had time to spare. She contacted a nearby Planned Parenthood clinic to get an intrauterine device, which can cost up to $1,000 up front, but can last up to a decade. In other words, getting birth control for the entirety of the Trump administration would be unaffordable without insurance or the help of the Affordable Care Act's contraceptive coverage mandate — two things the president-elect has promised to do away with.
"I was one of the many women who called up Planned Parenthood immediately after the election to talk about more long-term birth control methods," Goldner said. "Once Trump won, the uncertainties surrounding availabilities of birth control, and how much various types would be covered, or what insurance I'd even have, basically pushed me into action."
Trump's victory isn't the only outcome of the 2016 election which has given Goldner reason to be uncertain about her health care moving forward. Congressional Republicans, who retained control of the legislature on Nov. 8, have plans to eliminate all federal funding to Planned Parenthood Federation of America in the early days of the "pro-life" Trump administration, Politico reports. GOP lawmakers have voted to do this nine times since 2015, according to a Planned Parenthood spokeswoman — but with Trump in the White House, they might finally be successful.
Come January, Congress is expected to include a provision to eliminate all federal funding for PPFA in its repeal of the Affordable Care Act, a move which tops the list of Republicans' legislative priorities. Cutting off Planned Parenthood has been framed, inaccurately, as a way to ensure tax dollars do not go toward abortion, but defunding will undoubtedly accomplish something else. It will leave millions of people — many of them people of color, but most of them poor and reliant on government insurance programs — without access to basic health care by the end of 2017.
Here's what "defunding Planned Parenthood" actually means
Contrary to what the word implies, "defunding" Planned Parenthood doesn't mean the government will be left with a pile of money it can just give to other clinics — though that is precisely what congressional Republicans have promised to do with the roughly $500 million PPFA receives in public funding. As the New York Times explained, "there is no item in the budget labeled 'Planned Parenthood.'"
Instead, Planned Parenthood, like many other publicly funded providers, gets federal funding through government health care programs, such as the Title X family planning program and Medicaid. Title X accounts for much of the government's actual "spending" on the organization, but the majority of PPFA's federal funding is Medicaid reimbursements. Under the Hyde Amendment, none of that money can be used to fund abortions, but Planned Parenthood is already preparing to lose it all.
"Obviously we are doing everything we can through advocacy and everything else to make sure we can continue to serve patients," Erica Sackin, a spokeswoman for Planned Parenthood, told the Washington Post. "But at the end of the day, this is a fight of a scale that we haven't seen before and we need to be realistic about how much is at stake."
Ultimately, if the government decides to cut PPFA's Title X funding and stop reimbursing the organization for Medicaid patients, it means many people with low incomes — primarily women of color — will be shit out of luck if they need any number of the services Planned Parenthood provides other than abortion.
That means patients who rely on government programs could lose access to cancer screenings (of which the organization provides at least 270,000 annually, according to a spokesman), STI tests or treatment (more than 4.2 million annually), breast exams (over 360,000 annually), birth control and related services (more than 2.9 million annually) and more. The reason won't be because PPFA will necessarily have to shut down clinics without government funding; it'll more likely have to turn away patients who can't pay.
Goldner is one of the estimated 60% of Planned Parenthood patients who benefit from government health programs. With federal funding for Medicaid and Title X, PPFA and other community health centers are able to provide a range of services at low or no cost, assuaging the concerns of patients with lower incomes who might otherwise struggle to cover the cost of reproductive care.
Some of the services PPFA provides, like inserting costly IUDs and other forms of long-acting reversible contraception, would be inaccessible without public funding or the ACA's contraceptive coverage mandate, even for people who make well above the Medicaid threshold.
If PPFA clinics can't accept Medicaid, providers won't be able to serve Medicaid patients unless they can pay out of pocket. In states which have already cut Planned Parenthood affiliates from their Medicaid programs, the consequences have been dire.
"For people who won't be able to pay, it literally is going to be a life and death situation."
Nicole Goodwin, a 36-year-old military veteran who lives in New York City, said she "couldn't go anywhere for proper health care" without Planned Parenthood. She has polycystic ovary syndrome, which went undiagnosed for years, and fears other providers will continue to offer unaffordable, ineffective care. Goodwin went to Planned Parenthood after a negative experience at the VA, and says she had come to expect a low level of compassion from health care providers.
"What I realized when it comes to adequate health care is that Planned Parenthood takes it seriously," she said. "I feel that in other situations, other people have mislabeled what [the organization] does, especially for the African-American community. I am an African-American woman; this affects my life. My health is a crucial factor in my life and the life of my daughter."
Goodwin's experience at Planned Parenthood was "a fundamental 180" from what she had encountered previously: she was not only able to get an IUD to deal with her PCOS, but was also encouraged to apply for Medicaid. Though she was denied government coverage for herself, she plans to take her 13-year-old daughter, who does qualify, to Planned Parenthood and Planned Parenthood only. But Goodwin doesn't know how she's going to pay for it if the organization is defunded.
"I'd rather pay for quality care than my daughter not receive any care," she said. "To be honest, I don't know how I will find a way to pay. For people who won't be able to pay, it literally is going to be a life and death situation."
The stakes are high — especially for poorer people of color
Goodwin is not wrong about the high stakes of cutting off PPFA's federal funding, especially for poorer people of color. It is not by coincidence the organization is the one of the largest health care providers for Medicaid patients and the 36% of Title X beneficiaries who receive family planning assistance at its clinics. It's also no coincidence that many of those same patients are people of color.
Black and Latinx-Americans are enrolled in Medicaid at twice the rate of white people, and make up approximately 15% and 23%, respectively, of the roughly 2.5 million patients Planned Parenthood sees annually, a spokesman said. Three-quarters of those patients have incomes at or below 150% of the federal poverty level.
In recent years, a majority of state Medicaid programs have reported a lack of health care providers, particularly of obstetrics and gynecological care. Over half of Planned Parenthood health centers, however, are located in rural or medically underserved areas; often, those clinics are the only ones around. That makes PPFA a crucial source of health care for people who can't schlep to the doctor for any number of reasons, from cost of transportation to inflexible work hours, to an inability to secure childcare.
"Race and class are so interconnected," Stephanie Croney, a reproductive justice fellow at the Black Women's Health Imperative, said in a phone interview. "If you can't make ends meet to put groceries in the fridge, or can't afford to ride the metro, how can you stop and actually ensure you're doing your well woman visit, that you're making your annual physical, ensuring you're accessing the right contraceptives, or getting STI screenings?"
The big problem with Republicans' plan
Lack of access to other affordable providers presents perhaps the biggest hitch in congressional Republicans' proposal to infuse mythical community health centers with funds which might otherwise go to Planned Parenthood. First and foremost, these other clinics just don't exist — at least, not without Medicaid expansion to the impoverished communities where they are most needed.
Even when there are other health centers around, and even if those health centers receive additional funding, there's no guarantee they can absorb the patients who will be shafted by Congress's defunding plan, according to Croney. If people no longer have the option to go to Planned Parenthood when it's the only option they've had, she said, it means "shifting an entire population to travel ... [and] overburdening community clinics that are already there."
"There are wonderful community clinics that are not affiliated with Planned Parenthood, but they cannot do it on their own."
"You can't just shift funding; there's also a capacity issue," Croney explained. "There will be longer wait times. There will be women who are reliant on public transit or others for transportation, who won't seek health care because they can't travel that far. There are wonderful community clinics that are not affiliated with Planned Parenthood, but they cannot do it on their own."
Even for patients who do have access to other health care providers they can afford, Planned Parenthood might remain their preferred provider for reasons which aren't directly tied to the brass tacks of insurance coverage, but still result from systemic inequalities in access to care. Discrimination on the basis of income, sexual orientation or gender identity can have a major impact on where and whether people seek medical assistance, says Dr. Diane Horvath-Cosper, a reproductive health advocacy fellow at Physicians for Reproductive Health.
"People who rely on Medicaid and other assistance programs for health care have come to expect in a lot of ways to be treated badly," Horvath-Cosper said. "It's a real reflection on some of the shame we put on people who need assistance, and also some of the stigma that comes with needing assistance to get health care."
Of course, that's not the only problem anti-abortion lawmakers seem to have overlooked. Eliminating PPFA's funding is framed as a way to ensure tax dollars do not in any way facilitate abortion, but it comes at an enormous cost to taxpayers.
In 2015, the Congressional Budget Office projected the net cost to taxpayers would be $130 million over a decade should Planned Parenthood be defunded permanently, due to the loss of contraceptive care it provides. Without access to publicly funded care, the Guttmacher Institute estimates United States rates of unintended pregnancy and abortion will increase 33%, while the teen pregnancy rate will go up 30%.
"We'll pay the cost elsewhere, through unintended pregnancy or cost of care for living with STIs, or for people who have been diagnosed with preventable cancers," Croney said. "When you cut access to abortion care, cut access to contraception and increase funding for crisis pregnancy centers, you see increases on the backend — more lives lost."
Unfortunately, Americans might see those effects sooner rather than later. In choosing to defund PPFA, whether in the earliest days of the Trump administration or later on, Congress will be choosing an uncertain future for millions of patients in the U.S., not to mention limiting the life expectancies of many of the nation's most vulnerable. No matter what happens to Planned Parenthood's funding, Americans will have to pay for it. In Trump's America, it looks like the cost is going to be high.