In many ways, Shauna Heckert, the executive director of Women’s Health Specialists of California, a group of six abortion clinics in Northern California, feels lucky to be working in a blue state. California abortion laws are among the most favorable to providers. The state is the only one rated A+ by the lobbying group NARAL Pro-Choice America in its state-by-state survey.

Yet even as her organization celebrates its 40th anniversary, Heckert worries that she may no longer be able to keep all of them open. In the past few years, she’s seen other small providers close their doors because they simply couldn’t afford to keep going. The fees for services they charged were too low, the reimbursements from Medicaid and insurance too small and too infrequent. And the demand for abortions has fallen with the rate of unwanted pregnancies. “We are a dying breed,” Heckert said. Clinics in California and around the country have stopped operating, not only because of restrictive legislation and policy changes but “because of economics,” she said.

As the Supreme Court debates a Texas law that has led to the closure of at least 20 clinics, providers and researchers are noticing a quieter trend: Abortion clinics are closing in blue states, too.

Twelve clinics have closed in California since 2011, along with three in Washington and a number in New York, New Jersey and Connecticut, according to data compiled by Bloomberg — all states considered relatively favorable to abortion rights because of their legislative policies. According to Nikki Madsen, executive director of the Abortion Care Network, a national association for independent abortion care providers, for every three independent abortion clinics in her network that close in more conservative states, about two have closed in more liberal states over the past five years. She broadly defines these more liberal states as those that offer Medicaid funding for abortion, almost all of which voted for President Obama in the 2012 election. (A representative for Planned Parenthood, the national organization that provides reproductive health services, including abortions, said that it did not have data on hand for Planned Parenthood clinic closures by state.)

Abortion providers in more liberal states may not have sustained the kind of legislative targeting being tracked in places such as Indiana or Arkansas. But the combination of the economic difficulties of operating a clinic, a generally hostile atmosphere and declining demand means that many clinics are shutting down.

Even in states that are friendly to abortion rights, the costs of operating a clinic can make it nearly impossible to keep one open. In 2011, 94 percent of abortion procedures, including both surgical and medication abortion, took place in clinics, according to the Guttmacher Institute, a research organization that advocates for abortion rights. Of those, independent clinics provided about two-thirds of abortions. Planned Parenthood provides the other third. Although Planned Parenthood is a 501(c)(3) charitable organization, small clinics usually have for-profit status and thus must operate as businesses.

They often have a hard time staying afloat. One important factor is the price of the procedure. Clinics try to keep the price of abortions as low as possible so women can afford the procedure, Madsen said. Women seeking abortions are usually poor: 42 percent have incomes below the federal poverty level, and most pay for the procedure out of pocket. State bans on insurance coverage for abortions mean that many plans exclude it. Ten states restrict coverage of abortion in all private insurance plans, and 25 states restrict abortion coverage in plans offered through insurance exchanges set up through the Affordable Care Act, according to the Kaiser Family Foundation. Nationally, women are twice as likely to pay for abortions using Medicaid as private insurance.

The inflation-adjusted cost of an abortion has remained relatively stable over time, despite increased restrictions that have compelled clinics to update their facilities and limit the provision of care to physicians, according to Guttmacher. In 2009, the average woman who had a surgical abortion at 10 weeks’ gestation paid $451 — about the same as in 1983, when adjusted for inflation. The average amount paid for a medication abortion, which account for 36 percent of procedures done before nine weeks, was slightly higher — $504 in 2011-12. “I had an abortion in 1970 in New York. It wasn’t even legal. I paid $200,” Heckert said.

Clinics also struggle to keep their budgets balanced when the reimbursements from Medicaid and insurers are low and sometimes slow to come.

The Hyde Amendment of 1976 outlawed the use of federal Medicaid funds to cover abortions except in cases of rape, of incest or when the life of the woman is in danger. On paper, 17 states instead use their own funds to cover all or most abortions deemed “medically necessary,” an assessment usually left to physicians, according to Elizabeth Nash at Guttmacher. Even in these cases, however, clinics don’t always get the reimbursements they are due. A study of Medicaid reimbursements in 15 states found that in 13 of them, providers reported reimbursement for only 36 percent of qualifying abortions (providers in the other two states reported reimbursement rates of 97 percent). In Maryland, providers said they rarely sought reimbursements from the state Medicaid system because it was so difficult obtain them. One provider reported that Medicaid owed its clinic $90,000 in backlogged claims.

At Access for Women, an organization that provides abortions in Binghamton, New York, a first-trimester surgical abortion costs the clinic $400 to $425, office manager Peg Johnston said. For every surgical procedure the clinic gets about $330 to $340 in reimbursements from Medicaid. A cash fee of $500 covers the cost of the entire procedure, and private insurance rates are a little higher. “The problem is that about 55 percent of our patients are at the Medicaid rate, Johnston explained. The clinic loses $90 to $110 every time a patient on Medicaid gets an abortion. This “is hard to make up,” Johnston said.

“We’ve cut every cost we could think of. We have cut salaries. We haven’t given raises. We’re still hanging on by our fingernails,” she said. Raising rates or not taking Medicaid has never been an option, she said, because it would mean turning away the bulk of their clients.

Rules and regulations, such as waiting periods or requirements for surgical centers, can further increase costs for providers. New Jersey, for example, has long stipulated that abortion services after the 14th week of pregnancy be provided only in a “licensed hospital” or a “licensed ambulatory care facility,” according to NARAL. Upgrading an abortion clinic into a surgical center can cost as much as $750,000.

At the same time, fewer women are seeking abortion services, potentially reducing patient numbers at small clinics. In the U.S., 1.06 million abortions were performed in 2011, the last year for which Guttmacher has data for all 50 states, down 13 percent from 1.21 million in 2008. (In 1991, the number was almost 50 percent higher, at 1.56 million procedures.) Johnston says her clinic sees about a third fewer patients than it did a decade ago.

Restrictive legislation in some states may push women to get abortions in others, driving up demand. An Associated Press survey of abortion statistics in 45 states found that abortion rates had gone up by 18.5 percent in Michigan and 11.9 percent in Louisiana from 2010 to 2014 after legislation in Ohio and Texas shut down clinics in those states. “The Detroit clinics increased numbers hugely when Ohio shut down lots of clinics,” Johnston said. But demand declined in every other state, irrespective of legislation.

Evidence suggests that the drop in the abortion rate is in large part due to better access to contraception. Increased use of long-acting reversible contraceptives such as intrauterine devices has led to a drop in unintended pregnancies. The number of women seeking abortions has declined in turn.

Last fall, the Summit Women’s Center clinic in Bridgeport, Connecticut, closed, citing declining abortion rates. Director Tanya Little told the Connecticut Post, “Education, access and insurance coverage related to sexuality, contraception, pregnancy prevention and reproductive health care have made the need for abortion less and less in our state.”

But even as fewer women are seeking abortions, clinic closures could mean that women face greater barriers to abortion access. “People in need of abortion care have to drive further, expend more financial resources to access abortion care, and abortion is further stigmatized — creating a two-tiered system where access to abortion becomes a privilege for people with the most power and resources,” Madsen said.

Because most abortion procedures happen in small clinics, the practice has been “siloed from other care and other reproductive health care,” said Kelly Baden, director of state advocacy at the Center for Reproductive Rights, an abortion-rights nonprofit organization that is representing Texas abortion clinics before the Supreme Court. Some clinics have tried to integrate abortion care with other aspects of women’s medicine in order to stay afloat. “We are seeing many abortion clinics expand their services to reach some of the other health gaps in reproductive health care,” Madsen said. Although clinics have long offered contraception and counseling services, Madsen said she sees more clinics expanding into other aspects of women’s health care, including birthing, Pap smears, cancer screenings, miscarriage management and insemination services, as well as health care for LGBT patients.

At Buffalo Womenservices in Buffalo, New York, for example, Dr. Katharine Morrison splits the week among different aspects of reproductive care. Part of the week, she sees transgender patients, gay and lesbian patients, and women who want gynecological care and natural birth care. Two days a week, she performs abortions. She didn’t choose to expand her clinic’s offerings for economic reasons, she said, but providing a range of services has helped her to stay open. “Birth centers close for financial reasons,” she said. “Abortion clinics also close for financial reasons.” Integrating the two “works from an economic and political standpoint.”

When she started working in Buffalo in the late 1980s, she said, patients could get abortions at one of four hospitals or three abortion clinics. Many doctors performed abortions as part of their general practice. Now, no local hospitals perform the procedure, Morrison said, adding that only one other doctor in the area still provides abortions (but doesn’t take Medicaid). Morrison said two Planned Parenthood clinics nearby provide abortions, but only in the first trimester. If Morrison’s clinic were to close, she worries that a Buffalo woman on Medicaid seeking an abortion later in her pregnancy would have to drive six hours to New York City.