Paulette Hilton has been going to the same health clinic on Eastern Parkway in the Brownsville neighborhood of Brooklyn, New York, since 1998. She's 44 and has six children, and she saw the same midwife for prenatal visits during all of her pregnancies.
Her three daughters, who are in their 20s, also get care at the Brownsville clinic. "I love all of the doctors. They treat me with respect," Hilton said. "The clinic is so welcoming, so that's like a part of my home." A clinic staffer, known as Miss Sharon, who has worked there for more than 20 years, even calls Hilton on her birthday.
The clinic is run by Public Health Solutions, one of its two sexual and reproductive health centers in Brooklyn. The clinics have become trusted providers for many. It's not uncommon for the staffers to treat generations of families.
But now, the two clinics are set to lose nearly $1.8 million in state funding based on Gov. Andrew Cuomo's latest Fiscal Year 2022 budget proposal. Without the funding, the clinics would shutter, and 3,500 patients — primarily women of color living on low incomes — would have to go somewhere else.
The Cuomo administration did not respond to requests for comment.
Hilton knows it's possible that the clinic might close, and she said she doesn't know where she — or her daughters — would go for their gynecological care. She has gone elsewhere in the past, but "just the kindness, the love that you get, it just didn't compare," she said. "They show that they care about you — like, they make sure you're OK."
In a post-pandemic environment in which state and local budgets are tightening and people are losing their employer-sponsored health insurance, funding cuts for clinics like these could mean less access to medical care for people living on low incomes and people who are uninsured or underinsured. Often, reproductive health clinics like these are the only source of health care for low-income communities. Before Covid-19, the U.S. was already facing a maternal health crisis, with pregnancy-related death rates much higher than those of other developed countries. The disparity is even worse for Black women.
Most of Public Health Solutions' patients are Black or Latino and have incomes under the federal poverty line. Many have health insurance through Medicaid. The state funding helps subsidize care for people unable to pay, so the clinic doesn't have to turn anyone away, including undocumented people, and it also helps young people get care privately without using their parents' insurance, said Dr. April Lockley, the centers' medical director.
Public Health Solutions offers low- or no-cost reproductive health care across people's full spectrum of needs, including birth control counseling, testing and treatment for sexually transmitted infections, midwife-led prenatal care and referrals for adoption and abortion, Lockley said.
She also said that most of the staff members are people of color and that many have worked there for years. "Our team really reflects the community," she said, adding, "Patients really come to know us."
If the clinics were to close, local private OB-GYN offices might not accept patients with Medicaid or without insurance; even now, some new patients tell Lockley that they came to Public Health Solutions because they couldn't get appointments at other nearby providers for weeks. Federally qualified health care centers don't specialize in family planning services, and they are less likely than reproductive health clinics to offer contraceptive methods on-site.
Simply put, the clinics fill a unique role in predominantly Black neighborhoods. Public Health Solutions pairs pregnant patients with midwives they will see throughout their pregnancies, which isn't typical at hospital clinics. It also connects people to doulas, who provide both physical and emotional support through pregnancy and childbirth, and have been linked to better health outcomes, including lower rates of cesarean sections and preterm births, shorter labor and higher maternal satisfaction, according to the March of Dimes. Black women in the U.S. are three times more likely to die from pregnancy- and birth-related causes than white women are, according to the Centers for Disease Control and Prevention. In New York City, the gap widens: Black women are eight to 12 times more likely to die, according to the city health department.
Lockley said she has conversations "on a weekly basis" with patients who are thinking about having children someday but who are scared "about the racism within health care and how the rates of maternal morbidity are so high."
Clinics like Public Health Solutions aren't easily replaced by OB-GYNs and hospital clinics, said Dr. Herminia Palacio, a former deputy mayor for health and human services, who is CEO of the Guttmacher Institute, a reproductive rights research organization. Not only are community clinics financially more accessible for people while still letting them build relationships with their providers, but patients may also experience implicit bias at private medical offices based on their identity.
Palacio, who said she is "unmistakably" Afro-Latina, recounted a personal example. When she was pregnant, she had her first prenatal visit at a medical office of the university where she was a member of the faculty. The receptionist asked for her Medicaid card rather than simply ask for her insurance card. "This was a private practice, and this wasn't some place where the majority of the patients were Medicaid," she said. "It's important to understand how insidious these things are. People don't even hear themselves when they're saying these things."
That kind of bias in health care can extend to providers' not taking pregnant patients' concerns and symptoms seriously. Prenatal care is often considered essential to ensuring a healthy baby, but to prevent serious maternal health issues and deaths, providers need to care for the mother as a person, "not mother as incubator for baby," she said.
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Dr. Laurie Zephyrin, is an OB-GYN and the vice president of Health Care Delivery System Reform at the Commonwealth Fund, an organization that advocates for high-quality health care for vulnerable populations. She said having fewer places to get reproductive and prenatal care could have a big impact on people in those communities. "It could be devastating for pregnant and birthing people and their families" and could lead to more maternal complications and deaths, Zephyrin said.
Low-income communities are already hurt by the lack of investment in community health centers and primary care providers. "When we look at other high-income countries like ourselves, they invest in universal health care, they invest in primary health care, and they have lower maternal death rates and maternal morbidity rates, and those are all connected," Zephyrin said.
"Community health centers are places that we need to invest in — not just keep the lights on — we have to truly invest in them," she said.
At issue for the two Brooklyn clinics is $1,780,304 in the fiscal year 2022 budget that was previously allocated to Public Health Solutions. It got that funding as a backstop to federal funds it lost during the Trump administration. In 2019, the Legislature approved $16 million in replacement funds for Title X, a 50-year-old federal family planning program that the Trump administration altered to try to restrict access to abortion. Under the Trump administration's rules, even Title X grant recipients that provide abortions with other sources of funding or offer only abortion referrals, as Public Health Solutions does, were no longer eligible for the program.
Nearly 900 reproductive health clinics nationwide lost funding as a result, and Public Health Solutions almost closed the clinics in August 2019 when the state was slow to release the emergency funds. The clinics received the emergency money, but it expired Wednesday. While the Biden administration is working to undo the Trump administration's changes by the fall, it will be months before clinics can receive funding under the new rules.
Public Health Solutions' CEO, Lisa David, said the $1.8 million previously earmarked for the clinics wasn't cut from the budget entirely; rather, it was moved to the health department's budget line, and the organization doesn't expect to qualify for a grant. She said that if the state doesn't restore Public Health Solutions' Title X replacement funding in the final budget due Thursday, it will initiate closure plans Friday.
"I can't run these programs on half the revenue for nine months," David said. She noted that the state received more money than expected in the American Rescue Plan, the Biden administration's Covid-19 relief program. "This is solvable, and I think they have the resources to solve it. But everyone is extremely distracted in Albany," the state capital, David said.
Latavia Hippolyte became a patient because her mom goes to Public Health Solutions. Hippolyte, 19, a mother from the Crown Heights neighborhood, has been going to the Flatbush Avenue clinic since she was 15. She used to have an intrauterine device for birth control but didn't like it and had it removed by a different doctor, an experience she described as "horrible."
She said that the doctor didn't explain the removal process and that she aggressively questioned her about why she wanted it out. "She was like: 'Oh, you're just going to get pregnant again. You don't want another baby.' It was just like, 'You're not my mother.'"
Hippolyte said she is worried that Public Health Solutions could close. "I really, really like it there," she said. "Like, where am I going to go now?"