116 3rd St SE
Cedar Rapids, Iowa 52401
BETTENDORF — A wall in the Planned Parenthood Bettendorf clinic is lined with handwritten notes. They're from patients and supporters — thanking the clinic's staff for all the work they've done.
Some are colorful. Some are several paragraphs long. Others just simply read 'love your kindness' and 'thank you for serving women.'
But the notes also are a bittersweet reminder to employees of the people they'll no longer be able to help. The final day of operations for the clinic, along with three other Planned Parenthood locations — in Sioux City, Burlington and Keokuk — was Friday, June 30.
The Quad Cities clinic will continue telemedicine abortion services until the end of the year or the building is sold.
The closures come after Iowa's Republican-controlled legislature shifted family planning funding away from the organization and others that perform abortions during the 2017 session. The state has decided to forgo federal dollars to cover services such as birth control, sexually transmitted infection testing and Pap smears for low-income Iowans. Instead, it uses $3 million of state money for a similar program that excludes abortion providers. No federal or state dollars are used to pay for abortions.
That move hit Planned Parenthood of the Heartland hard — taking a nearly $2 million chunk out of its budget. The women's health organization announced in mid-May that it would close one-third of its Iowa clinics, affecting more than 14,600 patients.
'It's just so frustrating to think that we can't be a provider here anymore,' said Angela Rodriguez-Finch, the clinic director for six years. Rodriguez-Finch spoke with The Gazette from her office on Monday, five days before the facility would close. 'It's not (whether the care is) good enough or not good enough — what it is, is, 'I don't like that entity.''
Her emotions swing like a pendulum. She is angry and sad and fearful for her patients. She said she doesn't understand why other community providers are able to continue participating in the family planning network, but Planned Parenthood is not.
'It's like a witch hunt — 'I'm going after that organization, I don't care what good they do, and I don't care about the impact on the communities they serve. It doesn't matter,'' she said.
Employees at the Planned Parenthood Quad Cities clinic are proud of their work and brag about the quality of their facility. Everyone, from the nurses to the clinic manager, comment on how nice the space is and how some patients are surprised by that. Planned Parenthood is so often a political football, patients expect the facility to be dreary and rundown, employees said.
In its final weeks, the clinic was scheduling as many patients as it could to renew their birth control prescriptions or receive an annual exam.
'Patients are very upset and really don't know where they're going to go,' Rodriguez-Finch said. 'We have not done a lot of record releasing (to other health facilities) because they need to think about things.'
'It's just so frustrating to think that we can't be a provider here anymore. It's not (whether the care is) good enough or not good enough — what it is, is, 'I don't like that entity.''
- Angela Rodriguez-Finch
Director, Planned Parenthood of Bettendorf
Madie Zanger, 21, was there on Monday receiving a checkup one month after getting an intrauterine device, or IUD. She has one semester of nursing school left and isn't on her parents' insurance plan, so she's thankful she is able to receive services through Planned Parenthood.
'I have no idea where I'll go' after the clinic closes, she said. 'It makes me really angry.'
Zanger said she might try to travel to the Planned Parenthood location in Iowa City because she has access to a car, but that can be burdensome.
'I have religious parents. They hate everything that this place stands for,' she said. 'It's frustrating that abortions are the only thing it's associated with.'
Gabrielle Hill, 26, and the mother of a one-year-old son named Quinton, was at the clinic Monday to get a birth control prescription while she still had the chance. She's a full-time student, and she and her husband are not ready to have a second child.
Planned Parenthood became one of her very few options after a doctor's group no longer would accept her due to her outstanding labor bill, which totaled $4,000. She's working to pay it off, she said, but she needed care in the interim.
'A lot of people don't have a husband and the support I have,' she said. 'They need access to services like this.'
From three to one
Available family planning services in the Quad Cities are being hit especially hard. Around the same time that Planned Parenthood of the Heartland announced it would close the Bettendorf clinic, the Rock Island County Health Department across state lines in Illinois came to the decision to stop offering family planning services on June 30.
Given the state's overall financial issues, the county department has seen significant cuts in state funding — 64 percent since 2010 — for family planning services through Title X, health department chief operating officer Janet Hill said. It's not alone, she said, adding 'many, many county health departments across Illinois' have come to the same conclusion.
'We were able to subsidize it for a while,' she said. 'But we just can't anymore. When we made the decision, we hadn't heard about Planned Parenthood.'
The health department still will offer testing for STI — sexually transmitted infection — through funding it receives from a separate pool of money as well as case management for women with breast or cervical cancer, she said. But it will not be able to offer any forms of birth control other than condoms.
'Nobody is happy about this,' she said. 'We've been offering family planning services since the 1970s — there is no more basic health effort than helping a woman decide when to have a baby and to stop unwanted pregnancies.'
All of this means low-income women in the area who are uninsured or on Medicaid now have very few options left. Much of Planned Parenthood Quad Cities clinic staff now will be commuting to work out of Iowa City, and they hope some of their current patients will be able to follow them there.
But that hourlong drive creates barriers to access — patients will need to take more time off work and have access to transportation. For those who can't travel to Iowa City, they are likely to find refuge at Community Health Care (CHC).
The Federally Qualified Health Center has six locations throughout the Quad Cities area, including a women's health center, and serves low-income patients.
The organization feels confident it can absorb the patients from both Planned Parenthood and Rock Island County Health Department, chief executive officer Tom Bowman said. Two years ago, after undergoing a community needs assessment with other area health care providers and some strategic planning, CHC started adding staff who specialize in women's health.
OB-GYNs were retiring and Illinois providers were not accepting as many Medicaid patients, he said, so CHC added a midwife, nurse practitioners and its own OB-GYN. They also took over management of a Davenport women's health clinic in April 2016.
'Between that and the medical clinics, we have enough capacity,' Bowman said, though he added it is hard to predict how many new patients CHC will see.
There are about 1,400 unique patients at Planned Parenthood annually plus another 1,000 people who obtain family planning services at Rock Island County Health Department. Meanwhile, CHC sees about 35,000 patients a year, Bowman said. He is unsure what percentage of those getting primary care services with the health center have gone elsewhere for reproductive health care.
He plans to add support staff to the women's health clinic to accommodate the influx in patients.
'I didn't anticipate the clinic closing here,' he said. 'It did come as a surprise. But this is what FQHCs (Federally Qualified Health Centers) do. We try to pick up the pieces.'
But Rodriguez-Finch is concerned about what happens to Planned Parenthood's most vulnerable patients — those who cannot pay for services, those obtaining birth control confidentially so parents or partners are not alerted, and those who need assistance after being sexually assaulted.
'We had a patient Friday that we worked with, she was raped,' Rodriguez-Finch recalled. 'We went through all the testing with her, got the medication she needed and worked with her — we close at 2 — we worked with her all the way until 5 o'clock. ...
Will that happen? Or will be people say, 'Oh, we're closed, that's too bad.''
A birth control gap?
When talks swirl of defunding Planned Parenthood, one major concern experts have revolves around access to birth control. Planned Parenthood has a wide range of methods available from the pill and injectable shots to long acting reversible contraception (LARC) such as intrauterine devices and the implant.
They're all available on site — with patients having the option to receive them the same day as other services — and regardless of a patient's ability to pay.
'For Planned Parenthood and other safety net providers who focus on reproductive health, this is what they do — they deliver certain services and focus on them,' said Kinsey Hasstedt, a senior policy manager at Guttmacher Institute, a Washington, D.C.-based policy and research organization that focuses on reproductive health.
That is not always the case for Federally Qualified Health Centers.
'I have religious parents. They hate everything that this place stands for. It's frustrating that abortions are the only thing it's associated with.'
- Marie Zanger
Planned Parenthood patient
FQHCs deliver primary care services — medical and dental — for infants to the elderly. They are an integral part of the health care safety net, often caring for a huge percentage of a community's Medicaid patients.
And while they can offer Pap smears and breast exams, Hasstedt said LARC — which is the most effective type of birth control — is not always a guarantee.
'With LARC, there are upfront costs, you have to ensure staff on-site is trained and know how to insert it and take it out,' she said. 'It's just a different method and requires different steps than handing someone a condom.'
A Guttmacher analysis done in May found that, if all Iowa Planned Parenthoods were to close, the state's FQHCs would have to triple their current contraceptive caseloads.
You don't have to look any farther than two Iowa communities with now-closed Planned Parenthoods to see potential rips in the safety net.
The CHC's Bowman said Quad Cities' clinics should be able to provide LARC to any patient seeking it — the state of Illinois more adequately reimburses FQHCs for the cost of the birth control and the Iowa clinics soon will be the Title X provider in the community, which will offer it additional federal dollars for family planning services.
But drive an hour and 30 minutes south to Burlington or Keokuk and the situation becomes entirely different. Community Health Centers of Southeast Iowa, which operates four FQHCs in the area, is unsure if clinics will be able to offer LARC to patients.
That's because FQHCs have a different reimbursement mechanism than other health care providers such as Planned Parenthood. FQHCs are paid a lump sum for each patient visit to cover the cost of all services received — no matter what service is provided or the cost associated with that service.
And that dollar amount does not cover the cost of LARC because, unlike Illinois, the state of Iowa does not have an exception when it comes to reimbursing that service.
The availability of effective birth control has a direct correlation with national trends that show a decline in unintended pregnancies and abortions.
In 2014, the abortion rate fell to its lowest number since Roe v Wade was decided in 1973, according to a January study by Guttmacher. The number of abortions in Iowa dropped 23 percent between 2011 and 2014, from 5,640 — or at a rate of 9.7 per 1,000 women — to 4,380 — or 7.5 per 1,000 women.
Democratic state legislators and family planning experts have said since the start of the defunding debate in Iowa that they are concerned about women's ability — especially those women who are low-income — to receive adequate access to birth control if any Planned Parenthoods were to close.
'I am opposed to abortion and therefore in favor of access to birth control,' said Mark Anderson, a pastor and chairman of the Iowa Council on Human services, during the group's most recent June meeting.
Iowa's Department of Human Services — which will administer the new state funded family planning network — will collect data regarding access to services and providers for the first six months of the program. It plans to present those findings to legislators in January as well as the Council on Human Services, DHS's oversight council.
'You can tear a hole pretty quickly,' Guttmacher's Hasstedt said. 'But it will take a lot longer to knit it back together. In the meantime, there are a lot of women who will fall through it.'
These clinic closures in Iowa are not happening in a vacuum. As Congress debates what to do with the nation's health care system while it tries to repeal the Affordable Care Act, the potential for more safety net providers to close their doors in Iowa and across the country grows.
'The thing that is important about Iowa is that it could be a precursor for what's to come across the entire country if Trumpcare is passed by the Senate,' said Cecile Richards, president of Planned Parenthood Action Fund, in a conference call with reporters before President Donald Trump visited Cedar Rapids June 21. 'Trumpcare has similar language to the Iowa bill, prohibiting patients who rely on Medicaid — nearly half of the millions who rely on Planned Parenthood — from turning to Planned Parenthood.'
Steep cuts to Medicaid — through rolling back funding for the Medicaid expansion population as well as placing per capita caps on the entitlement program — could limit access to all medical services. But the Senate bill also would bar Planned Parenthoods from receiving any Medicaid reimbursements for one year.
This move would reduce spending by about $225 million, from 2017 to 2026, according to the Congressional Budget Office. But those savings would be offset by a sharp rise in births as low-income women are not able to access birth control.
The CBO believes the defunding measure would increase the number of births in the Medicaid program by several thousand. This then would increase direct spending for the program by $79 million as the children likely would qualify for Medicaid and other entitlement programs. Two Republican senators — Lisa Murkowski of Alaska and Susan Collins of Maine — currently plan to introduce an amendment that would get rid of the provision.
But for the four communities in Iowa who said goodbye to their Planned Parenthoods on Friday, that could now become a reality.
'When it comes to family planning, people don't think of it as an urgent need,' said Planned Parenthood's Rodriguez-Finch. 'But it really is. If you a young person in your reproductive years and you want to get birth control, and you have to wait a month or six weeks to be seen — you know sexual activity is going to happen. ...
It does matter. It really does, and it will have an impact on all of us.'
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