New abortion regulations just might help Planned Parenthood, rather than hobbling it.
A slew of new state laws, which require abortion-providing facilities to make upgrades such as wider hallways, larger rooms and temperature controls, are shuttering independent clinics at a faster rate than Planned Parenthood centers, which has more money with which to make upgrades.
That's helped the country's largest abortion provider expand its market power, performing ever more of the country's abortions and establishing itself as the most powerful, well-funded advocate for abortion rights in America.
"I think what people don't understand is Planned Parenthood is the Walmart of the abortion industry," said Kristan Hawkins, president for the anti-abortion group Students for Life of America. "They literally prop up all the other abortion providers in the country because they are the ones who set the messaging, they're the ones with the lobbyists on Capitol Hill."
Planned Parenthood says the many new regulations have prompted it to close some centers, but it won't say how many. But even while it operates fewer clinics than before, it now performs more than one in three abortions in the U.S., compared to just 12 percent in 1997.
That's due to several factors, and Planned Parenthood was growing long before states began passing regulations targeted at abortion providers. Still, some anti-abortion activists worry that the new laws are actually making Planned Parenthood more powerful by putting smaller competitors out of business.
"I think that's certainly something people in the prolife movement have raised," said Michael New, a government professor at Ave Maria University, who has worked for the anti-abortion group Americans United for Life.
"You might create a situation where there are fewer facilities doing abortions but those that are, are stronger, I think that's plausible," New said. "The concern has been raised, I'll just say."
In 2005, there were close to 600 independent abortion providers in the country, according to the Abortion Care Network, which represents independents. It says the number had fallen to 358 providers by last December, mostly clinics and a few hospitals and doctors' offices.
Most of these clinics are for-profit, meaning that unlike Planned Parenthood, they can't raise money to get on better financial footing. Network Director Nikki Madsen says that by her count, independent clinics have been closing their doors at a rate of 1.5 per week nationwide.
"They don't have that financial flexibility," Madsen said.
Planned Parenthood had about 860 clinics in 2005 but now has fewer than 700, according to its latest annual report. But many of the centers that closed offered only health services other than abortion. In some states, Planned Parenthood has been the dominant abortion provider able to comply with the new, stricter facility rules.
Planned Parenthood expanding
Take Texas, for example. Before the Republican-led legislature passed sweeping abortion regulations in 2013, the state had 46 abortion-offering facilities, of which fewer than a third were operated by Planned Parenthood.
Now Texas clinics must meet higher standards formerly applied only to ambulatory surgical centers. Of just nine remaining abortion clinics that comply with the new law, five are Planned Parenthood centers. All of them are in the state's largest metropolitan areas.
Planned Parenthood already had two centers that met the surgical standards long before they became mandatory. It opened an abortion clinic in Houston in the early 2000s and another one in Austin a few years later. As the law was being debated and passed in 2013, Planned Parenthood opened another abortion clinic in Fort Worth. Since then, it's opened two more: one in Dallas and another in San Antonio.
A federal court has temporarily suspended Texas' surgical center requirements until the Supreme Court rules on them this summer, allowing around 19 clinics to remain open for the time being. But should the justices uphold the law, Planned Parenthood would be the provider best positioned to stay in business.
"They have positioned themselves very strategically to continue to make abortion readily available in Texas should H.B. 2 go fully into effect," said Joe Pojman, director of Texas Alliance for Life, a group that heavily advocated for the new regulations.
Pojman admits that from a purely economic perspective, the new law helps Planned Parenthood, which isn't a side effect abortion foes expected or wanted as they fought to get the law passed. They just wanted new standards that might push some providers out of business and thereby reduce the number of abortions.
"It was kind of anybody's guess to see how many facilities would decide to upgrade," Pojman said. "Now Planned Parenthood has done it better than anybody."
Planned Parenthood has legally challenged two other aspects of the Texas law, which restricts off-label use of abortion-causing medications and requires providers to get admitting privileges at a nearby hospital.
But Planned Parenthood has not challenged the surgical standards part of the measure. It is not among the plaintiffs in Whole Women's Health v. Hellerstedt, the case the Supreme Court will hear on March 2, although it did file an amicus brief asking the court to strike the law.
Instead, it's the smaller abortion providers who are suing. Whole Women's Health is a chain of clinics, which formerly operated five centers in Texas but has closed two, one in Austin and one in Beaumont. Only one of its three remaining centers in the state qualifies as a surgical center under the new rules.
Whole Women's Health is basing its argument on a standard for state abortion regulations the Supreme Court outlined, but didn't clarify, in the 1992 case Planned Parenthood v. Casey, known as "undue burden." It's arguing that the Texas law is so unnecessarily onerous that it will force most clinics to shutter and leave many Texas women without sufficient access to abortions.
Planned Parenthood has been preparing for the possibility of the court upholding the Texas law and applying the ruling broadly to similar regulations in other states. Surgical center requirements are in effect in 22 states, according to the Guttmacher Institute.
In December, Planned Parenthood opened a new abortion facility in Louisville, Ky. It is being fought by Republican Gov. Matt Bevin, who says Planned Parenthood hasn't obtained a license, but the clinic does meet the state's surgical center requirements.
In North Carolina, which passed surgical center requirements three years ago, Planned Parenthood opened a new $2.9 million center in Asheville, meeting the new standards. It's now the only abortion provider in the western part of the state, after an independent provider, Femcare, closed.
Planned Parenthood bruised, but largely unscathed
In some respects, Planned Parenthood has had a rough couple of years. Videos by investigator and activist David Daleiden exposed the group for supplying aborted fetal tissue, and prompted a quest in Congress last fall to end its public funding. States followed suit, and some GOP governors are trying to block Planned Parenthood from getting federal Medicaid reimbursements for non-abortion services.
Yet Planned Parenthood has managed to avoid serious damage to its federal cash flow, and in fact increased its take of government money by three percentage points last year. President Obama vetoed the bill, which would have blocked it from getting Medicaid and Title 10 family planning dollars.
And as the overall U.S. abortion rate has declined over the past few decades, Planned Parenthood has steadily increased its share of total abortions performed in the country, a procedure that brings in more revenue than many other services, costing anywhere from a few hundred dollars to $2,000.
Some people in anti-abortion circles express concern about their movement's focus on Planned Parenthood rather than on all abortion providers. The fear is that by attacking just one provider, they might shift attention away from abortion itself, which is the thing they actually oppose.
While the House defunding bill last year didn't name Planned Parenthood, the legislation would have hit only Planned Parenthood because the legislation applied only to abortion providers that collect more than $350 million in Medicaid reimbursements.
But anti-abortion advocates and Republicans say publicly that their focus on Planned Parenthood is appropriate, given its increasing dominance of the market.
"Planned Parenthood is not only the biggest presence in the country when it comes to abortion advocacy, they've been the ideological driver of the ideas behind the abortion culture," said Russell Moore, president of the Southern Baptist Convention's Ethics and Religious Liberty Commission.
"I don't think talking about Planned Parenthood means we don't talk about abortion in all its manifestations, but Planned Parenthood really does drive the conversation," Moore said.
Rep. Marsha Blackburn, the Tennessee Republican who heads a select committee that grew out of the Planned Parenthood investigations, said it makes sense that her party spends so much time trying to undermine Planned Parenthood.
"Since they are the largest single provider, that is why the focus is there," Blackburn said.
But Blackburn stressed that she wants to expand her special committee's focus to a much broader theme than just Planned Parenthood's involvement in supplying aborted fetal tissue to biomedical companies. The 13-member committee, which Blackburn said is still getting organized, will look at the relationships between tissue procurement organizations and any abortion clinic that supplies them with tissue.
It frustrates Blackburn and her staff that the special committee has been widely referred to as a "Planned Parenthood panel." They want people to see it as a serious investigation of how the remains of aborted fetuses are used for medical research.
"It deserves to be looked at in total," Blackburn said. "People think we are right in broadening the conversation."
For independent abortion providers, Planned Parenthood on one hand provides a voice in Washington, D.C., because it spends heavily lobbying for legislation that supports abortion rights and against bills undermining clinics.
Planned Parenthood's lobbying spending has dramatically increased over the past decade. Up through 2007, $550,000 was the most the group ever spent in a year. But after doubling its lobbying spending in 2008, the group's expenditures peaked at $1.9 million in 2011. Last year, it spent $1.3 million, according to the website Open Secrets.
Besides performing a large share of abortions in the country, Planned Parenthood is also operating a larger share of clinics, as the overall number of providers has dramatically fallen. Back in 1982, more than 2,900 abortion providers operated in America, according to Guttmacher. By 2011, that had fallen to 1,720.
The result was that Planned Parenthood became the leading voice and industry standard on abortion rights in the U.S.
"They are driving the rest of the industry," said Abby Johnson, a former Planned Parenthood clinic director in Texas who now opposes abortion. "All of these individual providers, they take their directives from Planned Parenthood, so whatever Planned Parenthood does is what these individual providers want to do."
Madsen, director of the Abortion Care Network, says a variety of providers are essential to "a healthy abortion care ecosystem," including both Planned Parenthood centers and individual clinics. "The reality is, when Planned Parenthood is under attack, our providers are under attack," she said.
At the same time, Madsen feels the role of independent providers and the new state regulations' disproportionate impact on them is not understood. When she tells people she represents independent abortion clinics, most people are surprised, she said.
"People say I didn't know there were independent abortion providers, I thought it was just Planned Parenthood," she said.
Besides being able to raise money to cover costs, Planned Parenthood offers a range of healthcare services, including birth control and testing for sexually transmitted disease, for which Medicaid dollars can pay. Of the group's $1.3 billion in revenue last year, $353 million came from private donations and $553 from government reimbursements, according to its latest annual report.
Independent clinics, most of which are for-profit and don't offer the same range of services as Planned Parenthood, have fewer sources of money, said Jen Boulanger, communications director at The Women's Centers, a chain of five abortion providers in Pennsylvania, Georgia, New Jersey and Connecticut.
Clinics can get Medicaid reimbursements for abortion services only if they're in the 15 states that allow state dollars to be used that way. Federal Medicaid dollars can be used only for abortions in cases of rape, incest or if the women's life is at stake. So for the most part, if abortions are all a clinic provides, they don't have the same access to public funds that other providers do, even if they serve the poor.
Boulanger said her organization recently had to upgrade its clinic in Atlanta and another in Philadelphia to comply with surgical center standards. Upgrading the Philly clinic cost at least $200,000, she said.
"We're barely surviving," she said.
Having a larger organization to fall back on, such as clinics operated by Planned Parenthood, would be helpful, Boulanger said. But Women's Centers has no plans to expand, she said.
"It does hurt the independent clinics," Boulanger said. "We are struggling."
Madsen, Boulanger and other abortion rights advocates are careful not to criticize Planned Parenthood. But behind the scenes, clinics don't always refer patients to other centers for services they aren't able to provide. Johnson said that during her employment at Planned Parenthood, she typically wouldn't refer a patient to an independent provider.
"Planned Parenthood is very protective of their brand, and they do a good job of protecting their brand and that's why their brand is so successful," Johnson said.
Neither Planned Parenthood nor the National Abortion Federation would comment on-the-record.
If stricter regulations mean fewer abortion clinics, they could increase demand for Planned Parenthood centers that can afford to comply. Pojman said he's certain Texas' law has unintentionally strengthened Planned Parenthood in the state, although he feels passing the requirements was still the right thing to do.
Other anti-abortion advocates don't see a problem with closing independent abortion clinics at a disproportionately fast rate. Johnson feels that for the anti-abortion movement, it's still strategic to narrow the list of opponents.
"Anytime you win a war, you have to narrow down your attack to one enemy," Johnson said. "We are essentially taking out these smaller clinics one at a time."