Why It's So Hard To Run An Abortion Clinic
Bloomberg Businessweek|February 29 - March 6, 2016

Why it's so hard to open an abortion clinic - and why so many are closing.

Meaghan Winter

Hoping to publicize her new nonprofit, last fall Julie Burkhart called her local NPR affiliate, KMUW in Wichita, about buying a day of sponsorship for $480. Station manager Debra Fraser decided immediately that KMUW wouldn’t allow it. “I didn’t want to upset the apple cart,” Fraser says.

The response wasn’t new to Burkhart. In April 2013 she had reopened and renamed Women’s Health Care Services, where her former employer and mentor, Dr. George Tiller, provided abortions from the 1970s until 2009, when he was shot in the head and killed while ushering at his church. Today, South Wind Women’s Center offers abortion and OB-GYN services as well as transgender care such as hormone therapy. Burkhart hopes to install a birthing center. In the basement, Trust Women, the center’s umbrella nonprofit, runs a political action committee, continuing the advocacy Tiller began in the 1980s.

“We are only asking to be treated like any other business that provides health care,” Burkhart wrote in a letter to KMUW appealing the station’s rejection. She says a man in the development office told her that if the station accepted South Wind’s sponsorship, it would have to accept sponsorship from anti-abortion organizations, too. “The fundraiser in me thought, What’s the problem with that?” Burkhart says with a laugh. But she was taken aback, she recalls, when he asked if she thought KMUW should also take donations from the Ku Klux Klan. About that, Fraser says: “I certainly would hope that no one on my staff would say that. That doesn’t represent what I said to Julie.”

Burkhart and Fraser met for lunch. Fraser had previously worked at a Texas station where listeners frequently called to complain about Planned Parenthood’s sponsorship. As a news organization reliant on listener support, KMUW couldn’t afford to create the perception that it was “taking a stand” on abortion, Fraser says. “If I were you,” she remembers telling Burkhart, “I’d be really upset about this. But I can’t help you.”

The stigma around abortion prevents Burkhart’s nonprofit from performing many of the everyday transactions essential to businesses. She and other clinic owners have had trouble securing mortgages, medical insurance, contractors, and someone willing to deliver Band-Aids and bottles of water. Especially in rural and conservative regions, a wide range of companies and organizations decline to work with abortion providers, either for reasons of personal conscience or because of fears that being associated with abortion will cost them business.

In recent years states have enacted hundreds of laws designed by activists to make it more difficult—and more expensive—to perform abortions. Twenty-two states require abortion clinics to follow codes comparable to those of ambulatory surgical centers; at least 11 states specify the width of clinic rooms or hallways. Many clinics struggled to stay in the black well before legislation required them to remodel their corridors.

A common allegation by anti-abortion activists is that the doctors providing such services are in it for the money. “Their focus is where the dollar is. It’s not protecting women,” says Melissa Conway, a spokeswoman for Texas Right to Life. “Especially within the last few years, the cost of abortion services is increasing, and so it’s a very profitable business.” For many anti-abortion advocates, that standalone clinics provide most abortions is proof that “abortionists” are seedy characters who aim “to garner financial gain on the backs of women,” as Conway puts it. Texas Right to Life and its parent organization declined multiple requests for evidence that running an abortion clinic is lucrative.

The numbers suggest the opposite. The average amount paid for an abortion nationwide—about $450 for the most common procedures—has been relatively stagnant for decades, despite inflation in other areas of medicine and higher costs. In the 1970s anti-abortion attorneys formed a decadeslong plan to craft and lobby for state regulations that would gradually strip away physicians’ ability to provide the procedure. Much of the legislation makes it more expensive for clinics to operate, and the strategy has proved effective. Since 2011 at least 162 abortion providers have closed or stopped performing abortions, and 21 clinics have opened. That represents the swiftest annual decline in the number of abortion providers ever, according to Bloomberg News. Burkhart is working to start another clinic, in Oklahoma City, which she estimates will cost $1 million. No one has opened an abortion clinic in Oklahoma since 1974.

In 1976, Congress passed the Hyde Amendment restricting the use of federal funds for abortion, which Americans United for Life helped defend before the Supreme Court in 1980. In 33 states, Medicaid can’t be used to cover the procedure in most circumstances. Recent polling finds that almost half of women who obtain abortions live below the federal poverty line. Meanwhile, 10 states, including Kansas and Oklahoma, ban all insurance plans—and 25 states restrict government marketplace plans—from covering abortion except in rare circumstances. With a large share of women, including the poorest patients, paying out of pocket, many abortion providers keep their prices low. “What you’re doing is—as much as you can—not pricing people out of getting this service,” says David Burkons, a physician who opened a clinic in Ohio last year.

Clinic directors say the political climate ha.s made it almost impossible to open clinics. “You’d think, This is crazy,” says Amy Hagstrom Miller, founder and chief executive officer of Whole Woman’s Health, which has acquired or opened clinics in five states since 2003. She’s the plaintiff in the coming Supreme Court case over abortion laws that have shuttered two of her five Texas locations. Arguments begin on March 2. The extra costs she and other providers face are at the heart of the case: The decision will largely come down to whether the justices think the laws have made it too expensive for clinics to operate—and to what extent that burdens patients. Says Hagstrom Miller: “This is probably the most difficult business you could ever run.”

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