Laurent Delli-Bovi is used to operating her Brookline, Massachusetts, abortion clinic in a state of financial precarity. Women's Health Services, which has been around for almost 28 years, has been in the red for the last 13 of them.
Delli-Bovi, the clinic's medical director, said those years have mostly consisted of "robbing Peter to pay Paul": putting off paying some bills in favor of more urgent ones. The independent clinic runs on a "day-to-day" basis, its future never guaranteed.
But recently it's become untenable. After losing a chunk of grant funding earlier this year, WHS will have to close within the next three months unless it either finds a new funding stream or locates a larger clinic network, hospital, or individual donor to acquire the clinic. In the meantime, WHS is trying to get by on the funds it's raised through a GoFundMe its staff launched on December 2—as of this writing, the clinic has raised about $15,400 of its $250,000 goal. The purpose of the GoFundMe, Delli-Bovi said, is to buy time.
"Truthfully, we've been living this way for a very long time," Delli-Bovi said. "The difference now is that we haven't received any of the funding we need to offset our debts. There really isn't a way forward for us."
Independent clinics are clinics that aren't connected to national organizations like Planned Parenthood. And most of them are familiar with the circumstances Delli-Bovi describes: According to a new report from the Abortion Care Network, a national association of independent abortion providers, 39 indie abortion clinics closed in 2018 and 2019, and the total number of indie clinics in the United States has fallen by more than 32 percent since 2012, as a states have enacted hundreds of anti-choice laws making it harder for people to access abortion, as well as more difficult for clinics to operate. This has had devastating effects, as indie clinics provide 58 percent of all abortions.
Though larger clinic networks aren't immune to the effects of state- and federal-level abortion restrictions, they tend to hit independent clinics like WHS even harder, even when those clinics are located in blue states like Massachusetts that are not hostile to abortion rights. When the Trump administration announced that providers receiving money from Title X, the nation's only federally funded family planning program, could no longer refer people for abortions, all 31 indie clinics in the Abortion Care Network left the program, giving up millions in federal funding.
Planned Parenthood left the Title X program as well, but since it's a nonprofit, the organization is eligible for many grants and alternative funding streams that indie clinics—most of which are for-profit businesses—are not. And Planned Parenthood's staff and infrastructure mean it has the capacity to raise millions of dollars each year in private donations.
"By virtue of being independent, these indie clinics aren't connected to a large organization or larger system that can provide a safety net, or centralized marketing, communication, and fundraising," said Jay Thibodeau, the communications director at the Abortion Care Network. "Every individual clinic is on their own when it comes to making sure that donors and volunteers know about them. When you're operating this way—essentially as a small business—you're much more vulnerable because you don't have that scaffolding of support."
Thibodeau said another factor that makes indie clinics more vulnerable to closure is the fact that they are often one of just a handful of providers in their states—or, in the case of Kentucky, North Dakota, and Mississippi, the sole provider—which makes it easy for anti-choice lawmakers to tailor legislation targeting them.
This type of legislation is known as a TRAP law, which bury abortion clinics under costly and medically unnecessary regulations. In 2013, more than half of the abortion clinics in Texas shuttered when they weren't able to comply with HB2, a TRAP law which required providers to have admitting privileges at nearby hospitals. Many of the clinics that closed their doors were indies that couldn't afford to meet the requirements, and most of them haven't been able to reopen, despite the 2016 Supreme Court decision that declared the law unconstitutional.
The services indie clinics provide often can't be replaced if they close. According to the Abortion Care Network report, more than 82 percent of indie clinics offer both medication abortion and in-clinic abortion care, whereas just 44 percent of non-indie clinics offer both options. Most non-indie clinics only provide medication abortion, a procedure only available to patients in their first trimester of pregnancy.
And though the vast majority of abortions occur in the first trimester, when barriers to abortion or unexpected complications result in the need for an abortion later in pregnancy, it is more likely patients will receive that care from an indie clinic: Sixty-nine percent of all clinics that provide abortion services after 16 weeks are indies. After the 22-week mark, they make up 94 percent.
"Independent abortion providers are a key part of the ecosystem of abortion access, and are essential parts of their communities," said Bonyen Lee-Gilmore, the director of state media campaigns at Planned Parenthood Federation of America. "They serve the lion's share of patients in need of safe and legal abortion nationwide—and when state politicians chip away at abortion access, independent providers can carry the heaviest burdens while fighting with fewer resources."
Because WHS is the only non-hospital clinic in the state to provide abortions later in pregnancy, Delli-Bovi has had to staff the clinic with anesthesiologists and build an ambulatory surgical center in order to comply with the mandate—a $1.5 million undertaking. These costs have made the everyday demands of running an independent abortion clinic too expensive to sustain, Delli-Bovi said. And since low-income people make up a large percentage of the patients the clinic serves, WHS sometimes doesn't take any money for its services. "No one gets turned away if they can't afford to pay,' Delli-Bovi said.
Alison Dreith, the deputy director at Hope Clinic in Illinois, said that much like WHS, her clinic has been in the red for the last decade due to waiving the costs of patient procedures. Because it borders Missouri, a state with just one remaining—and endangered—abortion clinic, Hope Clinic has seen a surge of patients, more than half of whom are Missourians.
"We know patients are dealing with so many hurdles to get to us," she said. "We don't want to be another one."
If WHS is forced to close its doors in the coming months, that means the only option for patients seeking abortion after the first trimester will be a local hospital, where the cost of the procedure will be much higher, or a clinic out of state. "We're not financially sustainable, but we're worthy of being sustained because of the people we take care of," Delli-Bovi said.
"I think it's the same struggle everywhere—no one is in this business to make money," she continued. "It's a completely non-remunerative business. People do it because they're committed to the care."
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This article originally appeared on VICE US.