Among the various chances that congressional Republicans have taken in
their effort to repeal and replace Obamacare, one of the riskier moves involves the federal defunding of Planned Parenthood. In both the House
and the Senate, replacement legislation has included a provision that
would cut off all federal Medicaid payments to Planned Parenthood for one year.
(The bill would also bar federal tax credits from being used to purchase
private health plans that cover abortion.) The provision is reportedly
included even in the so-called skinny repeal. The Senate parliamentarian has determined that the provision violates
the Byrd rule, which states that a reconciliation bill can only address
matters that affect the federal budget; if the anti-Planned Parenthood
provision cannot be passed under reconciliation, it would require sixty
votes to pass. Many observers expect Senate Republicans to rework the
language in the bill so that it can stay in reconciliation. Ted Cruz,
meanwhile, has suggested that the parliamentarian’s ruling can be ignored.

That Republicans have taken things this far is a testimony to just how
important defunding Planned Parenthood has become to many of them.
Planned Parenthood operates more than six hundred clinics across the
country, and a majority of its patients have incomes that fall near or
below the federal poverty level; the organization receives around forty
per cent of its revenue from federal funding, mostly through Medicaid.
Cutting off those payments would be a drastic change for women’s health
care in this country. For a glimpse of just how drastic it would be, we
can look to Texas, where state legislators have been systematically
defunding and handicapping Planned Parenthood for years. Currently, the
Texas legislature is in special session, and three more anti-abortion
measures have already been passed. One of them prevents local and state
government agencies from contracting in any way—including via lease
agreements—with clinics that are affiliated with abortion providers.
As with the federal provision attached to the repeal of Obamacare,
Planned Parenthood is not mentioned by name in this Texas bill. And yet,
as Texas senators acknowledged last Friday, the
bill only affects Planned Parenthood. (Calls to multiple state senators
who sponsored the bill were not returned.)

The campaign against Planned Parenthood in Texas kicked off in 2011, a
point when, as Lawrence Wright noted recently in the magazine, the organization was serving sixty per cent of the health needs of
low-income women in the state. In the 2011 legislative session, which
Texas Monthly called “the most aggressively anti-abortion and
anti-contraception session in history,”
the state government cut family-planning spending by two-thirds and
approved a budget that, starting in 2013, banned Planned Parenthood from
participating in the state’s women’s-health program, now called Healthy
Texas Women. Federal law requires that states allow Medicaid patients
their choice of “any willing provider,” and so Texas had to give up a
nine-to-one federal funding match. Millions of dollars in spending for
women’s health care were turned away. Then, this past May, Texas asked the Trump Administration for that federal funding back—a request that,
if approved, would signal to other states that Planned Parenthood can be
banned from Medicaid family-planning programs at will and with no
financial repercussions. According to the New England Journal of Medicine, sixteen additional states have already proposed or approved
similar bans.

It’s possible that, even if Planned Parenthood is defunded at the
federal level by current Republican efforts, funding might be restored
by subsequent legislation. But Texas provides a startling example of how
quickly the women’s-health landscape can be wrecked by a withdrawal of
resources—and how lasting that wreckage can be. Within months of the
family-planning budget getting slashed in Texas, more than sixty
women’s-health clinics had closed. Such effects can take years to undo,
even if laws are reversed. In 2016, the Supreme Court overturned a Texas
law that had halved the number of abortion clinics in the state. Only
two clinics have reopened. The sprawl of Texas is almost
incomprehensible—it’s the same distance from Houston, my home town, to
El Paso as it is from Houston to Kansas City—and that sprawl means that
rural clinic closures bring immediate and catastrophic consequences for poor women and women without cars. Teen abortions and
teen births have both been increasing in Texas since 2011, and the
maternal mortality rate in Texas doubled from 2010 to 2014. It’s now
35.8 deaths per hundred thousand live births—the worst maternal
mortality rate you can find in the developed world.

Last week, I spoke to Caroline Coyner-Such, a clinician who has been
working in health care for forty-three years, twenty-seven of those at
Planned Parenthood. She now works at a clinic in North Austin, one of
three in the Austin area that collectively serve nearly nineteen
thousand patients each year. “Twenty or thirty years ago,” she told me
over the phone, “we saw mainly women under the age of thirty-five. These
days, as Texas women lose access to other options, we’re seeing more
women, and a wider range of women—preteens up to women in their fifties
and sixties.” The previous day, a homeless patient had come in. The
North Austin clinic provides well-woman exams, S.T.I. screenings,
cervical-cancer screenings, breast-cancer screenings, and birth-control
counselling, among other things. It does not provide abortion services,
but the surgical center at the South Austin location, thirty minutes
away, does.

As clinics in other areas have been forced to close, the Austin-area
clinics have begun seeing more and more patients from farther away.
“Yesterday, I saw a patient from Elgin, which is an hour away,”
Coyner-Such said. “We see people from Killeen, which is another hour
away. This means people have to take a whole day off from work to drive
to Austin to get basic services—which often used to be available in
their communities—and go back. We routinely send prescriptions out in a
seventy-five-to-one-hundred-mile radius.” The Austin-area clinics have a
base of private donors and local grants that they’ve been able to draw
from as they’ve scrambled to replace public funding; small clinics often
lack this piecemeal buffer, and rely more heavily on Title X, which is
Planned Parenthood’s other federal funding source.

“People are fearful,” Coyner-Such told me. “The summer is usually lower
in terms of patient numbers, but not this year.” The news is a constant
presence in her workplace, she said, with patients showing up afraid
that their insurance will be taken away, and with new regulations from
the legislature rolling in. “We have to be constantly monitoring in
order to know what we’re going to lose and what we have to recoup,” she
said. “It takes a lot of effort to stay on top of—I can’t believe I’m
even using this term, but—the fake news.” Patients are sometimes openly
surprised that the clinic is clean and professional, or that Coyner-Such
has specialty certifications. She knows the kind of campaigning she’s up
against. “Years ago, I had a Planned Parenthood bumper sticker, and
someone slashed my tires,” she said. “After that, I quit doing bumper
stickers—it’s not worth the tire replacement.”

The Republican health-care legislation asks that the landscape of
women’s care be reimagined without Planned Parenthood in it. But
without Planned Parenthood that landscape, particularly for low-income
women, scarcely exists. Pink billboards have gone up around Austin and
other major cities in Texas advertising the Healthy Texas Women program,
which does not provide abortion services and is explicitly intended to
redirect patients from Planned Parenthood, yet sixty thousand
fewer women are enrolled in the program than were enrolled in the Medicaid
Women’s Health Program in 2011, before Planned Parenthood was excluded.
Even setting aside the fact that comprehensive women’s health care
necessitates the option of safe abortion—and that the Hyde Amendment has
banned federal funding of abortion, with rare exceptions, since
1976—Planned Parenthood serves such a large portion of low-income women,
and has done so for so long, that other clinics are logistically
incapable of picking up the slack. “There is a real fear, if Texas
continues along this line, if they continue to downgrade our
funding—where will these women go?” Coyner-Such said. “Will they wait
six months for an appointment at another clinic? Or will they be
pregnant because they aren’t able to access our services?” Then she
excused herself, going back to the patients who awaited her.