Rebecca Cook / Reuters

Alexandra Rucinski has been a patient at the Planned Parenthood in Burlington, Iowa, since she unexpectedly became pregnant with her son five years ago. She was 22 years old then, and she didn’t have health insurance. So she drove to the clinic on North 8th Street, where staff helped her understand her options.

Rucinski chose to have the baby, and she has since continued to visit the health center regularly: every three months for her Depo-Provera shot, a form of injection contraception, and once a year for a breast and pelvic exam, so clinicians can monitor abnormal cells in her cervix.

On May 17, Rucinski got an email that her clinic is closing permanently.  

In one of his final acts before resigning to serve as U.S. ambassador to China, Iowa Governor Terry Branstad signed an appropriations bill into law. The legislation contained a short section discontinuing Iowa’s family-planning network waiver (IFPN), which allows people who don’t qualify for Medicaid to receive coverage for things like contraception, pelvic exams, pap tests, and STD testing. Instead, the bill establishes a new, state-funded program that prevents funding from going to abortion-providers.

This push to exclude Planned Parenthood from public funding in Iowa offers a preview of what could happen nationally, if Republican lawmakers succeed in passing legislation to defund the organization.

Suzanna de Baca, the president and CEO of Planned Parenthood of the Heartland, said the loss of funding from the IFPN waiver forced it to close four of the 12 health centers it operates in the state by the end of June. De Baca announced the closures in a press release, warning that “defunding Planned Parenthood will set a health care crisis in motion in Iowa.” And the move, which will displace more than 14,600 patients, has local health centers scrambling to figure out how to fill the gaps.

I wrote about the projected consequences of this kind of legislation back in March, when the family-planning waiver was a standalone bill called Senate File 2. Lawmakers who supported the bill didn’t want government funds going to Planned Parenthood and other providers that facilitate abortions, and they suggested that the nearly 4,000 patients who visited Planned Parenthood under the family-planning waiver could instead receive care at federally qualified health clinics.

At the time, those clinics told me they weren’t sure how they could take on those patients. They weren’t able to provide the long-acting reversible contraception that Planned Parenthood has readily available—things like IUDs and contraceptive implants. Ted Boesen, the CEO of the Iowa Primary Care Association, said then that he couldn’t “buy in” until he got answers from Republican lawmakers about funding.

But now, the IFPN waiver has been eliminated, and with it, roughly $2 million of Planned Parenthood’s funding. Four clinics are closing, which will displace nearly 15,000 patients, instead of the expected 4,000. “This is hot off the press. Everybody is trying to absorb,” Boesen told me this week. “Nobody likes to see this happen; the health centers in the communities certainly don’t.”

Boesen said it’s his mission to make sure those patients find care elsewhere, but he added that Planned Parenthood offers a “unique brand” of care. “We’re gonna do our level best to replace it, but there’s some dimension of that that isn’t replaceable.”

De Baca said the organization had been preparing for this eventuality for weeks, and told me they used a set of four factors to determine which clinics would be shuttered: patient numbers and access; community support, including the local donor base and the community’s fundraising capability; political support; and finally, the financial health of the clinic.

In the end, the organization chose to close its three remaining locations in southeast Iowa—Keokuk, Burlington, and Bettendorf—and Sioux City in Western Iowa. All but the Keokuk clinic provided abortions, but, Planned Parenthood noted, the Bettendorf clinic will continue to provide them indefinitely, even after it stops the rest of its services.

Siouxland Community Health Center is a federally qualified center in Sioux City that Republican lawmakers listed in March as an alternative for Planned Parenthood patients. “It would have been nice for legislators to maybe reach out to us to see if this is something we could provide,” Brendyn Richards, Siouxland’s director of development and advocacy, told me.

Richards does expect a large portion of the Sioux City Planned Parenthood’s roughly 4,800 patients to come to Siouxland, but he has a lot of unanswered questions. He’ll spend the coming days and weeks assessing exactly how many patients will come for care, from how far they will come, what services they need, and whether more staff will need to be hired.

Ron Kemp, the CEO of Community Health Centers of Southeast Iowa, said he’s met with several community-health providers to assess what the need will be. Two of Kemp’s clinics, in Keokuk and Burlington, will likely see a large portion of Planned Parenthood’s displaced patients.

One of his main concerns is increasing the clinics’ contraceptive capabilities. Occasionally, he said, his clinics actually refer patients looking for the more expensive, long-acting reversible contraceptives to Planned Parenthood. Those methods, which include things like implants and IUDs, “have historically been a financial issue for community health centers,” he said.

Another worry is that Planned Parenthood’s patients might be reluctant to seek out another provider. “Will people go without care?” Kemp asked, worrying that some will, “not because the capacity won’t be there but because we haven’t developed those relationships as providers.”

Many of Planned Parenthood’s patients are young people who visit their health centers, sometimes in a crisis, to get information in a safe, confidential environment. Richards, the Siouxland representative, said he’s concerned about replicating that: “They don’t want to go somewhere where they might run into their neighbor from down the street or their family member,” Richards said. “It would be tough, just losing that choice and that place that’s maybe more comforting and quieter to go to.”

All of that rings true for Rucinski, who was raised by conservative parents in a religious family in Burlington. She said there are a lot of conservative families in the area who don’t talk to their children about birth control. “A lot of times it’s their children who end up in the clinic and need help,” Rucinski said. “I was one of them. Planned Parenthood gave me the information that the adults in my life never did.”

Rucinski works at a diner in town, makes minimum wage, and now has health insurance through the individual market under the Affordable Care Act. She’s worried that she’ll have a hard time finding another provider in town that can fit her in for her regular birth-control injections.

“I feel like [Republicans] have taken away my choice,” Rucinski said. “I’m still responsible for figuring this out, but they’ve made it harder for me to make a responsible choice.”

Another Burlington patient, Sara Robinson, 33, told me she has a primary-care doctor, but she goes to Planned Parenthood for pap smears and exams—and has been for 17 years. “I just feel super comfortable down there,” she said. “They were the ones that helped me when I was younger with birth control and showed me my options. There were times I didn’t have insurance, and that was my only option, too,” she said.

“I’m impressed I haven’t said the ‘f’ word at all this whole time,” Robinson told me. “It’s thrown a wrench into everything.”

Natoshia Askelson, an assistant professor in the College of Public Health at the University of Iowa, said Planned Parenthood’s contraceptive capabilities, same-day appointments, and sliding scale fees make it a unique part of the public-health safety net. “We have federally qualified health centers, Planned Parenthood, free clinics,” she said. “These are the [providers] who are supporting to make sure people don’t completely fall and crash to the ground. That takes a big piece out.”

Patients with the resources and ability to negotiate the health-care system will be able to find replacement family-planning and reproductive-health providers but, Askelson said, “it’s the people who are living on the edge, working two or three jobs, maybe don’t have all their ducks in a row and struggle to get through the day who aren’t going to be able to figure out where to go next.”

The clinic closures in Iowa show that even seemingly insignificant attempts to cut Planned Parenthood off from public funding have a real effect on health-care access and choice for patients. At the national level, Planned Parenthood’s fate is in the hands of a majority-Republican legislature that has demonstrated a will to defund it: The Republican health-care plan that passed the House in early May contains a proposal to exclude Planned Parenthood from Medicaid reimbursements for one year. The legislation is likely to be significantly altered in the Senate, but if a similar provision passes, it would mean more surprising closures in communities across the country—and the displacement of thousands more Planned Parenthood patients.

Right now, in Iowa, “it’s here and it’s real,” Kemp, the Burlington clinic CEO, told me. “We have to take these initial discussions we’ve had as community health centers, we need to translate it into something real into the community.”

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