In the remote western plains of Texas, the Midland-Odessa region is separated from the nearest major city by hours of open road. So when the Planned Parenthood clinic in Midland closed down in late 2013 – a casualty of legislative cuts that targeted Planned Parenthood directly – it served as an isolated experiment in what happens when the government defunds the largest women’s healthcare provider around.

“I hate to say it, but I think an awful lot of women just opted to go without care,” said Mike Austin.

Austin is chief executive of Midland Community Healthcare Services (MCHS), a federally-funded network of providers that has emerged as the only major alternative to Planned Parenthood in the area. His clinic offers all of the same services the Midland Planned Parenthood once did, including contraception, cancer screenings and STI tests, to the same kind of patients, low-income women who rely on the public safety net for their healthcare.

In fact, just before the Planned Parenthood clinic shut down, the two providers made a plan to minimize the fallout. Planned Parenthood sent nearly 5,000 patient medical records – up to 1,000 belonging to active patients – directly to MCHS.

But to Austin’s dismay, only about 100 former Planned Parenthood patients ever showed up at his door.

“We are seeing a subsequent rise in STDs and a subsequent rise in unplanned pregnancies,” Austin said. He believes they could be linked. “And I’m sitting here going, ‘See? I told you so. This is what happens.’”

In the weeks ahead, members of Congress will attempt to replicate Midland’s experiment on a grand scale by defunding Planned Parenthood across the country. They will do so in the form of a budget that blocks Planned Parenthood from accepting Medicaid, the government-funded insurance for low-income individuals.

It’s a move Republicans have long framed as a rebuke of Planned Parenthood’s role in providing abortions – even though Medicaid is prohibited from covering abortions by law, and only half of Planned Parenthood clinics even offer the procedure.

What Medicaid does do is allow Planned Parenthood to provide contraception, cancer screenings and STI tests to 1.5 million patients in the public safety net at some 650 health centers for no cost. About two-fifths of the organization’s $1.3bn annual budget derives from public funding. Without the reimbursements Medicaid provides, a spokeswoman for the Planned Parenthood said, an unknown number of those centers will have to close.

House speaker Paul Ryan of Wisconsin recently predicted that federally funded health centers – like the one in Midland – could pick up where Planned Parenthood left off. “They’re in virtually every community,” he said at a recent town hall, “providing the same kinds of services.”

But public health officials such as Austin, who work in states where Planned Parenthood’s presence is already in decline, are sounding the alarm. They say the loss of Planned Parenthood would imperil the health of thousands of women who already face high barriers for care.

And some of the strongest voices in opposition come from Ryan’s own backyard.

“They’ve never replaced the services of Planned Parenthood,” said Gail Scott, director of health in Jefferson County, Wisconsin. Her county, which lost the Johnson Creek Planned Parenthood in 2013, bumps up against Ryan’s congressional district. “I’m not pro-abortion or anything,” she said. “But I can tell you nothing ever replaced those services for uninsured people.”

The clinics in Johnson Creek closed because lawmakers in Wisconsin, as in Texas, approved a series of family planning cuts targeted directly at Planned Parenthood. Today, Scott said, when the Jefferson County health department gets calls from low-income women looking for a place to obtain contraception, staff recommend they travel to another county – where there’s still a Planned Parenthood.

Chippewa County, Wisconsin, also lost its Planned Parenthood clinic. Jean Durch, the county health director at the time who is now retired, recalled that after the closure, there was no place in Chippewa for women to receive STI tests, even though her department sought the funding to make it happen.

“We never were able, before I retired, to pick up the full complement of services” of Planned Parenthood, she said.

And Shawano County, Wisconsin, which is experiencing a flare-up in gonorrhea and which the state government recently designated a hot-spot for new chlamydia infections, is still feeling the pressure. After the Planned Parenthood there closed, former patients faced significant waiting lists to see a doctor at local community health clinics. The health department didn’t know where to send women for certain services.

“The clinic that closed in Shawano served the whole county,” said Jaime Bodden, the Shawano County health director. Not just women on Medicaid, she said, but women with stingy insurance and women with no insurance at all. Now, the county health department is virtually on its own as it combats the region’s rising STI rates.

“It’s something that we still often talk about,” she said. “We say, ‘Wouldn’t it be nice to have Planned Parenthood in town?’”

‘A national healthcare disaster’

Planned Parenthood officials say Wisconsin would continue to be hard-hit if Congress went through with its plans for defunding. A disproportionate number of its patients there are Medicaid beneficiaries and women of color – groups of people who already face barriers to accessing care.

Already, some of their patients are worried about gaps in their health care if Planned Parenthood were to disappear.

“I have to get that care,” said Courtney Kessler, 22, of Madison, Wisconsin, who has a family history of ovarian cancer and has gone to Planned Parenthood for cancer screenings and contraception for seven years. She is on a public safety net program that covers the costs. “I don’t know where else I would go. I would have to spend time finding somewhere else to go, and worry about: can I afford it? And worry about: am I getting the same quality of care I get with Planned Parenthood? It’s only making it more difficult for people already having struggles.”

Planned Parenthood operates 22 locations in 15 Wisconsin counties, with just two providing abortion services. A new survey conducted by Health Management Associates, a healthcare consulting firm, and paid for by Planned Parenthood, concluded that in seven of those counties there are no viable alternatives to Planned Parenthood for family planning services. In four other counties, there is only one viable alternative. Two counties that would have no alternative if Planned Parenthood were to close – Racine and Walworth – comprise part of speaker Ryan’s district.

The notion that overnight they can serve two million more people who need reproductive health services is absurd Sara Rosenbaum, professor of health policy

The survey also concluded that many alternatives offer limited hours and do not stock all the most effective contraceptives – making it questionable that they are truly alternatives to Planned Parenthood.

Raegan McDonald-Mosley, Planned Parenthood’s chief medical officer, said this pattern holds across the country. In 332 of the 491 counties where it had locations in 2010, the latest year numbers were available, Planned Parenthood served at least half of the women obtaining contraception through the public safety net. In 103 of those counties, Planned Parenthood was the only safety net provider for family planning.

“We play a hugely important role in family planning safety net around the country,” said McDonald-Mosley. If those clinics were no longer options for many women, “It would truly be a national healthcare disaster.”

A woman has her blood pressure checked at a women’s clinic in San Juan, Texas. Photograph: Delcia Lopez/Reuters

Proponents of defunding Planned Parenthood have circulated their own surveys. In 2015, lawmakers and anti-abortion activists distributed maps and lists claiming there were thousands of government-funded health clinics able to take on Planned Parenthood patients. Several news outlets revealed that these lists included dentists, jails and food banks.



Still, many of the dots on such maps represent clinics that really do offer the same services as Planned Parenthood. The question is, can they take on potentially millions of new patients?

Many public health advocates are skeptical.

“Planned Parenthood treats about two million women on Medicaid and community health clinics in total serve about 25 million – everybody from infants to 90-year-olds,” said Sara Rosenbaum, a professor of health policy at George Washington University who has worked in the field of community health for several decades.



“They have wait lists for the people they’re serving today, much less having to absorb all of Planned Parenthood’s patients as well,” she continued. “The notion they can suddenly ramp up their capacity to absorb all of the services Planned Parenthood can offer, the notion that overnight they can serve two million more people who need reproductive health services is absurd. It displays, to my mind, an astounding ignorance of how the health system works.”

‘Texas illuminates what may happen’

Planned Parenthood hasn’t produced an estimate of how many of its clinics might close, and where if the group were defunded.

In Texas, though, a nascent body of research suggests that excluding Planned Parenthood from the safety net has negative consequences even when the cuts don’t force clinics to shut their doors.

These studies have measured what happens not when Planned Parenthood clinics closed, but when women enrolled in Texas’ Medicaid-like program can no longer use their insurance at Planned Parenthood. One study, from the Texas Policy Evaluation Project of the University of Texas-Austin, followed women in Midland (before the clinic shut down) and Houston who relied on Planned Parenthood for Depo Provera, an injectable contraceptive. They found that 20% of women who wanted to stay on Depo-Provera missed their next dose.

These women faced a small but real increase in their odds of getting pregnant. About 25% became pregnant – versus just 8% of the women who didn’t miss their next dose.

The other four out of five women in the survey who wanted another dose, got one. But it wasn’t always free, and it wasn’t always straightforward. Forty-three percent of these women reported that it cost them time or money to find a new provider. In Midland, because other providers were scarce, 65% of the women surveyed kept going to Planned Parenthood, even though it now meant paying out of pocket.

Defunding Planned Parenthood, in other words, didn’t necessarily stop women from relying on Planned Parenthood for health care – it just forced them to replace the state’s money with their own.

“These results should be cautionary to states considering similar measures,” the study warned. “They contradict the claim that Planned Parenthood could be removed from a statewide program with little or no consequence.”

Another study found that after Texas kicked Planned Parenthood out of the Women’s Health Program, there were drops of more than 30% in reimbursement claims for some of the most effective methods of contraceptives (although not birth control pills). The drops were only observed in counties where women had previously used local Planned Parenthood affiliates. That study also measured a small but real uptick in births by women on Medicaid, although there are other explanations besides the loss of Planned Parenthood.



“Texas’s experience illuminates what may happen on a larger scale,” said Joe Potter, a UT Austin researcher. “Each person involved in the program had to go find a new provider. And whether or not the new providers have the training, experience, and bureaucratic set up so women can get care promptly is a big question mark.”

Austin, who runs the clinic in Midland, says the problem isn’t just that local health clinics might not have the capacity. In fact, he was one of few public health officials interviewed who felt that federally funded healthcare clinics really could provide for Planned Parenthood’s patients – eventually.

“Logistically, yes, it can happen,” he said. “But it can’t happen for free or overnight. In Dallas or Austin, you could be talking about 10,000 people being displaced into the community health system. I’m sure [local clinics] would do their best, but it would take a ramp-up to do it.”

A Texas health department survey of the state indicates that the capacity to absorb Planned Parenthood patients might exist. But the problem, as Austin’s experience attests, is getting all of the same patients that Planned Parenthood once served through the door. Clinics like his also have an extremely limited ability to advertise their existence. Women know what Planned Parenthood is and the services it offers. And MCHS doesn’t employ the same medical professionals as Planned Parenthood – people that patients have trusted for years with personal and sometimes embarrassing issues.

All these could be reasons why hundreds of Planned Parenthood patients, unless they moved or found other care, never transferred to Austin’s clinic.

Recently, MCHS moved most of the 5,000 records it inherited from Planned Parenthood into storage.

“It broke my heart,” Austin said. “Here’s 5,000 people who have basically been thrown out on the street. What happened to them? I can only account for about a hundred of them. What happened to the rest?”