At reproductive health care providers across the country, many leaders say they were faced with an impossible choice as recipients of grants from Title X, the federal family planning program that provides affordable birth control.
They could follow a new Trump administration rule, announced in February, that bars Title X grantees from referring patients to abortion providers, a provision they say would severely compromise the care they offer.
Or they could refuse to comply, giving up millions of dollars in annual funds that pay for reproductive services for millions of women for everything from pregnancy tests to cervical cancer screenings.
For Planned Parenthood — which serves 40 percent of Title X patients — the decision was clear. On Monday, the last day to agree to the rule, the organization announced it was withdrawing from Title X rather than abiding by what it called an "unethical gag rule."
“I want our patients to know: while the Trump administration may have given up on you, Planned Parenthood never will. Our doors are open today, and our doors will be open tomorrow," Alexis McGill Johnson, acting president and CEO of Planned Parenthood Federation of America, said.
But how, exactly, to keep their doors open is proving to be a conundrum.
In interviews with clinics throughout the United States, most leaders said the loss in funding would not have an immediate effect on the care they provide.
But they worried what would happen long-term if the Trump administration requirement is not overturned. The rule faces legal challenges by Planned Parenthood and other organizations, plus more than 20 states, but a federal appeals court has said the policy can take effect as the cases are litigated.
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In Utah, where Planned Parenthood has been the state's only Title X grantee since the 1980s, clinics had already been doing "some belt-tightening" ahead of the expected loss of funds, Karrie Galloway, CEO of Planned Parenthood Association of Utah, said.
"We have made the commitment that we're not going to do any knee-jerk reactions," Galloway said. Her organization receives about $2 million in grants each year from Title X, which serves just under 37,000 patients at seven of the eight Planned Parenthood sites in Utah, Galloway said.
But the clinics may not be able to continue offering free care to all low-income women.
Instead of not charging patients at all who normally receive services for free under Title X, those individuals "may pay 10 or 15 dollars, but we are going to work with them to make sure that they get the access to basic reproductive health care," Galloway said.
Such a charge, she feared, could dissuade patients who live below the poverty level from seeking care.
"We're talking people who would have to decide, do we get dinner this week, or do we get to buy my birth control?" Galloway said.
In Minnesota — where Planned Parenthood serves 90 percent of the state's Title X recipients — Jen Aulwes, spokesperson for Planned Parenthood North Central States, said "the worst thing that could happen is people don't seek out the care they need and unintended pregnancies go up, STD rates could go up and cancer screenings could go down."
Title X dates back to 1970 and was created to fill in gaps in health care access and affordability, particularly for those in rural or otherwise underserved areas. Most of its patients are people of color, Hispanic or Latino, according to Planned Parenthood.
For patients who do not qualify for reproductive health care services through Medicaid or state family planning programs, "Title X is the safety net. It's the last in a waterfall of funding options that clinics go through with patients to make sure we can get as much of their care covered as possible," Aulwes said.
"When you're talking about the difference between paying nothing and paying 20 bucks for your care, that's a really big deal for a lot of people."
"This is going to affect people who are currently getting free care at our clinics. They are the youngest, most vulnerable patients," she said. "When you're talking about the difference between paying nothing and paying 20 bucks for your care, that's a really big deal for a lot of people."
Even without the $2.7 million annual Title X grant that the affiliate receives, "we plan to keep our doors open," Aulwes said, and the 26,000 people in Minnesota who rely on Title X funding for their care will still get services.
Both Aulwes and Galloway said front desk staff would work with patients to navigate insurance to see if they have coverage they don't know about, and will rely on donors.
Planned Parenthood is not the only organization balking at the administration's rule. In Maine, the state's only grant recipient of Title X, Maine Family Planning, is losing out on about $2 million by refusing to comply.
The money serves about 23,000 patients, many of whom "already face significant barriers to care," such as long travel times to clinics in remote parts of the state, Deirdre Fulton-McDonough, Maine Family Planning's director of communications, said.
For the immediate future, Maine Family Planning, which has 18 clinics, is relying on reserves. But "that is only a short-term solution and we are aggressively seeking other sources of public funding," Fulton-McDonough said, including talking with officials about funding from the state.
"If we are not able to secure an alternative source of funding, there will be a danger of having to close clinics."
"If we are not able to secure an alternative source of funding, there will be a danger of having to close clinics," she said.
In addition to banning providers from giving patients who ask for an abortion referral a direct answer, the administration's policy requires financial and physical separation between facilities that receive Title X funding and those that perform the abortions.
In rural states like Maine, that would be "cost-prohibitive when you're talking about these tiny clinics," Fulton-McDonough said. Like Planned Parenthood, Maine Family Planning is also suing in federal court to block the rule.
The policy has received backlash on the state level as well. Maryland and Massachusetts preemptively voted to opt out of Title X, replacing the grants with state funding if the rule went into effect. Hawaii, Illinois, New York, Oregon and Washington have said they will do the same, according to Reuters.
The rule places "personal, political points of view on the backs of our most vulnerable women," Galloway, of Planned Parenthood Association of Utah, said.
"It's just disgusting. It's reprehensible," she said. "But it's where we're at, so we're going to figure it out."