To be sure, the past decade has seen a withering Republican assault against women’s health clinics that provide abortion services.

GOP-dominated states have passed a wave of abortion restrictions since 2011.

As the Guttmacher Institute documented, between 2011 and 2015, states passed as many restrictions on abortion (288) as in the previous 15 years combined (292). Most of these took the form of Targeted Regulation of Abortion Providers (TRAP) Laws. This labyrinth of medically unnecessary and scientifically baseless rules on everything from requirements that clinics meet the same physical standards as surgical centers, mandates on physician admitting privileges at nearby hospitals, and even the width of hallway corridors are designed to disqualify many from legal operation. Even as these laws in states like Texas, Louisiana, and Mississippi among others fight their way through the courts, more onerous legislation on patient waiting periods and mandatory, invasive ultrasound procedures are placing an undue burden on women’s access to abortion services. As bogus “fetal pain” and “fetal heartbeat” bills proliferate in GOP-dominated states, others like Georgia and Alabama are essentially trying to ban the procedure altogether. (Unlike actual, living American women, they argue, fetuses enjoy due process and equal protection of law under the 14th Amendment.)

The impact has been staggering. By May 2019, the New York Times reported, only about 750 clinics nationwide provided abortion services. Researchers at the University of California, San Francisco, discovered that approximately 275 facilities nationwide had closed since 2013. Of those 750 still in operation, roughly 40% do not provide abortions after 13 weeks. Six states now have only one clinic each. Only a judge’s reprieve in June kept the only facility in Missouri open. These closures, along with the ready availability of new drug therapies, are fueling a sea-change in how American women obtain abortions. As NPR reported two weeks ago about the latest findings from Guttmacher on the nation’s abortion rate:

The report noted a 25% increase in the use of medication abortion, with nearly 4 in 10 abortions in 2017 being performed using abortion pills instead of surgery. The analysis also includes data suggesting an increase in women using pills or other methods to self-induce abortions without a medical provider's assistance; 18% of non-hospital facilities surveyed said they'd treated at least one patient for an attempted self-induced abortion — up from 12% in the last survey, according to Guttmacher.

But since Donald Trump ambled into the White House, the federal government has added its weight to the GOP states shuttering women’s health clinics. In 2017, Congress tried to follow the lead of states like Texas in prohibiting Medicaid dollars to be spent at Planned Parenthood’s 665 clinics around the country. Trying to sell that poison pill, then-House Speaker Paul Ryan wrongly claimed that it was the nation’s 13,900 “federally qualified health care centers” and rural health centers. But the former does not provide the range of contraceptive services as Planned Parenthood, while the latter are not required to serve clients regardless of their ability to pay. Neither provides abortion services.

Title X is the “gold standard” of public health care policy.

The immediate threat to women’s health clinics is the Trump administration’s war on Title X. Signed into law by President Nixon, Title X funds healthcare services for millions of low-income women each year. “It funds services including contraception, testing and treatment for sexually transmitted infections, and breast and cervical cancer screenings,” Health Affairs recently reported, adding that “Title X regulations prohibit funds from being used for abortion care, though health centers that provide abortions have received Title X funds.” Thanks to Republican opposition in Congress, funding for Title X has been slashed from its 2010 peak of $317 million to just $286 million in 2019. But it is President Trump who had done the most serious damage with his Title X “gag rule.”

In June 2018, the Trump administration published a proposal to revise existing regulations to Title X. The rule contains two key changes: one revision, referred to as a “gag rule” by its opponents, prohibits Title X recipients from providing referrals for abortion care, even when requested by the patient. Another revision requires Title X-funded centers to “establish and maintain physical separation” from the provision of abortion.

For Planned Parenthood and other providers of women’s healthcare services, the consequences have already been severe. To avoid running afoul of the gag rule, Planned Parenthood announced it would no longer request Title X funding, some $60 million or roughly one-fifth of its annual operating budget. As Planned Parenthood summed it up:

Title X helps prevent over 1 million unintended pregnancies each year. In 2016 alone, health centers used Title X funding to provide 720,000 Pap tests, more than 4 million STD tests (including HIV tests), and nearly one million women with breast exams.

While the Title X program provides care and services to four million women each year, 40% of them (or 1.5 million) receive those tests, treatment, and counseling through Planned Parenthood clinics. In 2018, Vox explained why so “many of those Title X patients seek care at Planned Parenthood clinics.”

This is partially due to the fact that Planned Parenthood exists in many places where other family planning clinics don’t: A new analysis from the Guttmacher Institute estimates that there are 103 counties in the United States where Planned Parenthood is the only provider of publicly funded contraceptives. In an additional 229 counties, Planned Parenthood serves the majority of women who are low-income and qualify for government help paying for birth control… Eighty-nine percent of Planned Parenthood clinics, for example, report being able to provide their patients with emergency contraceptives, compared to 34 percent of federally qualified health clinics (which typically serve low-income patients and are also a major recipient of Title X funding). And 81 percent of Planned Parenthood clinics say they provide same-day access to intrauterine devices (IUDs), the most effective type of reversible birth control. By contrast, just 30 percent of other clinics do that.

Title X and Planned Parenthood are essential for women’s health care in America.

While some clinics will close due to the loss of their Title X dollars, others will reduce hours, slash staff, and increase fees to clients who may not be able to afford them. Maine Family Planning is trying to make up a $2 million shortfall, one-quarter of its annual budget. Paulette McElwain, CEO of Virginia League for Planned Parenthood, warned of a “public health disaster” in Virginia. "We're going to see unintended pregnancy rates go up, we're going to see STD rates go up, HIV rates go up," McElwain says of the regulations. "But we're going to do our best to be here, no matter what, for all the folks that rely on us." As Health Affairs reported:

While litigation is ongoing and may still result in the courts overturning the administration’s rule change, there are already consequences for patients’ access to care. Two Planned Parenthood health centers in Cincinnati closed this month. In Minnesota, the Mahube-Otwa Community Action Partnership, a provider that serves patients in rural areas of the state, is facing a 50 percent staff reduction. Some health centers opting out of Title X have said that they will make up the lost revenue through charging patients additional fees and limiting hours, barriers that could deter care.

… a combination that can’t be quickly replaced.

Deter care, indeed. Between the state campaigns against abortion access and the Trump-Pence crusade against Title X providers, American women seeking the gamut of reproductive healthcare services will find fewer choices nearby or that they can afford. But even for those with the resources and insurance to pay for it, the continuing expansion of Catholic hospitals is making services like abortion, hysterectomies, and even some contraception options nearly impossible to obtain in some regions of the country. Just this month, Rewire News recounted the story of “a miscarrying woman [who] nearly died after a Catholic hospital sent her home three times.” While the Bellingham, Washington woman’s nightmare seems like it would be unusual in one of the progressive states now planning to fill the Title X shortfalls in their healthcare systems, it is not. Catholic hospital chains like PeaceHealth (which bans abortion unless its “direct purpose” is the “cure of a proportionately serious pathological condition of a pregnant woman” and it “cannot be safely postponed until the unborn child is viable”) account for over 40% of the hospital beds in the Washington state.

Back in 2010, the Guttmacher Institute looked into the “return on investment” of public funded family planning programs. The incredible “ROI,” in terms of both taxpayers and women’s lives, was clear:

The public investment in family planning programs and providers not only helps women and couples avoid unintended pregnancy and abortion, but also helps many thousands avoid cervical cancer, HIV and other sexually transmitted infections, infertility, and preterm and low birth weight births. This investment resulted in net government savings of $13.6 billion in 2010, or $7.09 for every public dollar spent.

Reflecting on that amazing data, in July Nicholas Kristof of The New York Times pondered why President Trump would put such a glorious public health success story in jeopardy. Referencing the Guttmacher research, Kristof lamented:

Title X is an odd target because it is the gold standard of cost-effectiveness. In 2010, one study found, publicly funded family planning averted 2.2 million unintended pregnancies, 99,100 cases of chlamydia and 3,680 cases of cervical cancer.

But with this month’s research confirming that women’s health clinic closures represent a death sentence for some patients and suffering for so many more, some of the women Kristof spoke to in West Virginia had better advice and better questions for President Trump. As Cassie, a 27-year-old woman who has been receiving birth control, breast exams, Pap tests, and more since she was 16 from the Women’s Health Center in Charleston, put it:

“If I would have gotten pregnant, I might have taken my own life,” she said, and she broke down, tears rolling down her cheeks. Her advice to President Trump and his aides: “You don’t understand until you’ve been in someone’s shoes. You’ve got to talk to these women.”

Linsley Myers, a 23-year-old community college student in Trump-loving West Virginia, echoed that sentiment. Her message to Trump: “Why attack women?”

Why, indeed.