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AROOSTOOK COUNTY, Maine — When Calleena Boyce learned her birth control was going to cost $147.75, she didn’t exactly say, out loud, that she couldn’t afford it.

The 18-year-old, tanned from long days working at a local day care, had sat and listened patiently as a nurse practitioner at a small health care clinic in the middle of northern, rural Maine, walked her through her options for birth control.

The nurse practitioner eased Boyce’s fears about IUDs — they can shift, but very rarely do. She warned her that estrogen-heavy contraception would likely magnify Boyce’s migraines. By the end, Boyce decided she wanted a Nexplanon implant, the most effective form of birth control.

There was just one issue: Boyce didn’t have insurance.

The $147.50 was just the down payment — Boyce would have to pay a total of $283.50. And that’s the discounted version. Without the sliding fee scale at the Presque Isle Family Planning clinic, the implant would cost Boyce $1,050.

Boyce could apply for MaineCare, the state’s Medicaid program, but she likely wouldn’t get approved for at least three months. What if, the nurse practitioner suggested, Boyce instead used her second choice of birth control?

“In a perfect world, we’d all abstain from sex, whatever. But that’s not gonna happen.”

A shot of the slightly less-effective Depo-Provera would cost her just $16.20 at the Presque Isle clinic, and it would protect her until she started college near Bangor, Maine, this fall. Once her university gave her coverage, Boyce could go to Bangor Family Planning, a sister clinic of Presque Isle, and get the Nexplanon implanted there.

“I honestly don’t know what I would have done if I couldn’t have come here,” Boyce told VICE News in an interview. “At least with my circle of friends, there’s a lot of lower-income families. This is where we get our free birth control and our free condoms, and stuff like that. The stuff we need. I mean, in a perfect world, we’d all abstain from sex, whatever. But that’s not gonna happen.”

After Boyce left, the nurse practitioner, Christina Theriault, said many of her appointments turn into a conversation about cost. “Here we are again, playing this game of ‘What can you afford?’” she said. “Which is not the way medicine should ever be practiced, but it is.”

It’s about to get harder. In mid-July, the Trump administration announced that providers who receive funding from the federal family planning program known as Title X would no longer be allowed to refer people for abortions. Within a day, Theriault’s employer, Maine Family Planning, became the first Title X grant recipient to announce it would rather withdraw from the program than comply with what it sees as a “gag rule” on providers’ ability to refer for a legal procedure.

Cassidy handles the front desk at both clinics in Presque Isle and Fort Kent, where she helps patients navigate their insurance (or lack thereof). She asked to be identified by her first name only. (Photo: Carter Sherman/VICE News)

Title X is the only federal program dedicated to funding family planning services, like STI tests, cancer screenings, and birth control, and about 4 million low-income people rely on it each year. Leaving it will mean that Maine Family Planning will lose $1.8 million annually, or roughly 30% of its total funding, which it doles out to 47 clinics across the state serving about 23,000 people.

Providers across the country are now weighing whether to stay and comply with the rule or forfeit millions and risk closing clinics. After Maine Family Planning’s announcement, Illinois Gov. J.B. Pritzker announced that his state would stop taking money from Title X too; the governors of Washington, Oregon, and Hawaii have made similar pledges in the past.

Planned Parenthood, which serves about 40% of all Title X patients nationwide, has also announced that it has stopped using the program’s money. Instead, the massive reproductive rights organization is now relying on limited emergency funds.

If these changes to Title X lead clinics to close, rural communities with few providers will be among the hardest-hit. The people of Aroostook County, where Maine Family Planning operates three clinics, could be forced to drive hours to find cheap family planning services. Or, potentially, they may simply choose to go without.

Evelyn Kieltyka, senior vice president of program services for Maine Family Planning, told VICE News that not taking the money is preferable to the alternative: not being able to tell patients where they can go to end a pregnancy.

“As a provider, it’s unthinkable that you can’t actually give your patient what you want,” she said. “And it’s incredibly safe, legal, available — and yet I can’t tell you where to go. There’s no other health care service where that kind of restriction is placed.”

Tammy Pelletier, 44, has gotten birth control from the Presque Isle Planning clinic for years. (Photo: Carter Sherman/VICE News)

Trump officials and anti-abortion advocates say that the changes to Title X are necessary to ensure that no taxpayer money “intermingles” with abortion services or “promotes” abortion. The new rules also stipulate the clinics financially and physically separate any services that involve abortion from those that don’t, though the latter requirement will not go into effect until next year.

“Planned Parenthood and others want to use public Title X funds to support their abortion services in blatant disregard of the fact that Congress explicitly and statutorily excluded abortion from the scope of Title X projects and funding,” Catherine Glenn Foster, president of the powerful anti-abortion group Americans United for Life, said in a statement.

It is already illegal to use federal funding to pay for abortions, except in the case of rape or incest, or when the pregnancy endangers the mother’s life. Many of the almost 4,000 clinics that rely on Title X don’t provide abortions at all.

Proponents of the Title X changes also argue that federally qualified health centers, which receive government funding to care for underserved communities, can step in to fill the void left by Planned Parenthood. But a Kaiser Family Foundation survey found that half of health centers say their staffers could only handle about a 10-24% increase in their patient loads, and clinics that don’t take Title X funding are also less likely to offer a full range of birth control options.

Patients at Fort Kent Family Planning can grab some free condoms before they leave. (Photo: Carter Sherman)

To compensate for the end of Title X, Maine Family Planning is trying to raise private donations and find other public funding sources. Deirdre Fulton-McDonough, director of communications for the non-profit, declined to say how long that money may last.

“Our reserves are not yet exhausted,” Fulton-McDonough said in an email. “Suffice to say, this is a short-term solution that we are actively seeking to resolve. For now, however, we are committed to not closing clinics and to preserving the network as it has been.”

The remote towns of Presque Isle and Fort Kent, which lie about an hour apart, both have Maine Family Planning clinics. In addition to providing Nexplanon, IUDs, and other family planning care, the clinics do offer medication abortion, enabled by telemedicine.

Only about 9,000 people live in Presque Isle, and another 4,000 in Fort Kent. (Both Presque Isle and Fort Kent are almost exclusively white, according to census records.) Ask people to describe the towns, and the same words will keep popping up. They’re “old-school.” They’re “traditional.” And they’re certainly “conservative”: Trump won Aroostook County in 2016 with 55% of the vote.

“People don’t talk about birth control, people don’t talk about sex,” said Rebecca, a 23-year-old nursing student who studies at the University of Maine’s Fort Kent campus. She started visiting Maine Family Planning for birth control after having an abortion, and asked to be identified only by her middle name. “It’s kind of stepped back in time.”

The towns’ residents must frequently drive hours to get what much of the rest of the country takes for granted. Hours from the nearest highway, Fort Kent is a two-stoplight town along the border of Canada and the St. John River. Its tallest building is the Catholic church’s gleaming white spire.

While Presque Isle has a mall, it’s a ghost town. On a recent Tuesday morning, a cluster of seniors played bingo in the remains of the food court, while, at the other end of the mall, so many stores had shuttered that management hadn’t even bothered to turn on most of the lights.

About a tenth of the patients at Presque Isle Family Planning relied on Title X in fiscal year 2019. (Photo: Carter Sherman/VICE News)

About a fifth of the patients who visited Fort Kent’s family planning clinic in fiscal year 2019 relied on Title X to help pay for their care; over that time period, about 10 percent of Presque Isle patients did the same.

“We have a lot of people who do things like hairdressing on the side, or cleaning houses, or working at the mill, or working at gas stations. They don’t make enough to get any coverage, and fall under the poverty level, even with working on the side,” said Theriault, who lives in Fort Kent with her husband and two young sons, but serves as the nurse practitioner at both clinics. “A lot of our patients come to see us and don’t have primary care providers, because they can’t afford it. But they can afford to see us.”

Tammy Pelletier started going to the Presque Isle Family Planning clinic six years ago, after she got divorced, lost her job, and was uninsured for nine months. There, she was able to get a shot of Depo-Provera every three months. Sometimes, she’d pay what she could; other times, she didn’t pay a dime.

“They were the one agency that was willing to help at the time,” said Pelletier, 44. “I had been going to my regular PCP [primary care provider] for all my woman care, but it wasn’t — when I started going to Maine Family Planning, it became a whole new experience for me.”

Even now that she’s employed, Pelletier says she still finds herself living paycheck to paycheck. A Republican, she’s not sure how the Trump administration’s changes to Title X will impact her vote in 2020.

“That doesn’t mean I agree with every decision Donald Trump makes, and this is a terrible one for women. I don’t agree with it at all, and that’s hard for me to say,” she said. Still, the Democrats running for the presidential nomination, Pelletier went on, “have pie-in-the-sky ideas, and I just don’t know if they know what it takes to accomplish that.”

There’s still some uncertainty over what lies ahead for Title X. Scores of states and reproductive health groups have sued over the rule changes to Title X, and a panel of judges on the U.S. Circuit Court of Appeals for the 9th Circuit have agreed to consider their challenge. But the 9th Circuit also ruled to let the administration implement the changes while that litigation plays out in the courts.

While Trump officials have said that the changes are in effect, they’re also giving clinics until September to actually prove that they’re complying with them. As long as providers show they’re making “good-faith efforts” to follow the new rules, they won’t face enforcement consequences.

In the meantime, few of Theriault’s patients know just how imperiled their providers are.

“It’s frustrating that for, much as we’re yelling and screaming and saying, ‘This is what’s going on,’ people aren’t hearing it,” Theriault said. “It’s gonna be most frustrating when it’s too late and we go under. And all of our patients are gonna be affected and all of our patients are gonna be screaming. But then it’ll be too late.”