When Morgan Johnson walked into her annual well woman’s exam at the Little Rock Planned Parenthood in 2018, the Arkansas clinic had just gotten a call from the governor’s office.

A new state law that had been working its way through the courts had just gone into effect — Planned Parenthood could no longer receive Medicaid reimbursements. That meant Johnson, then a student, single mom to twin girls and patient on the federal insurance program for those living in poverty, had to find a new provider. 

“I felt devalued as a person who didn’t have insurance,” she said, recalling thinking, “Wow, Arkansas really hates women. This isn’t about abortion.”

She said it took her months to get into a new provider who took her Medicaid because wait lists were so long.

A few years earlier, Johnson said Planned Parenthood had been her lifeline after she had an ovarian cyst rupture while she was uninsured. She said the clinic signed her up for Medicaid and got her into regular appointments, which ultimately kept her from leaving school, her initial plan once the debilitating pain began. 

“They were my doctor when I did not have one. If not for that, I probably would’ve dropped out,” Johnson said. “Who knows where I would be without them.” 

Arkansas’ law was upheld by the 8th U.S. Circuit Court of Appeals in St. Louis. Since then, Missouri has tried twice to enact a similar restriction through the state budget, both times ending with the state Supreme Court ruling the effort unconstitutional. 

Now, Missouri Republicans are trying again to replicate Arkansas, this time by changing state law. Proponents of Missouri’s legislation argue that no public funding should be going to clinics affiliated with abortion providers in other states. 

Planned Parenthood clinics in Missouri no longer offer the procedure, which has been nearly completely banned in the state since 2022. Their affiliates in Kansas and Illinois do.

Despite the legal victories, Planned Parenthood clinics have not received any Medicaid reimbursements since 2022. Emily Wales, CEO and president of Planned Parenthood Great Plains, which oversees clinics in western Missouri, Kansas, Oklahoma and Arkansas, said her organization has been privately fundraising to offset the cost of care to continue seeing Missouri Medicaid patients. 

But she’s not sure how sustainable that is. 

Asked if they would have to stop seeing Medicaid patients immediately if this legislation became law, Wales said they’re still evaluating their legal options and whether they might apply for federal funds.

“The real issue for us is that the public safety net for low-resourced patients in Missouri is already so strained that when you start using a very small number of resources and try to expand care, it’s just not possible,” Wales said. “It’s hard to imagine that there won’t be people who are affected — maybe not immediately — both in a matter of months where we’re just not able to cover the cost of care for everyone who needs us.”

Those who support the bills, including anti-abortion advocates, have said that it’s immoral for any public funds to go to groups that promote abortion. Historically, state leaders have agreed, prohibiting state money from paying for abortions even before the U.S. Supreme Court overturned Roe v. Wade.

Supporters of the proposed Missouri law argue the nearly one in five Planned Parenthood patients on Medicaid can simply find a new provider. Those opposed say that’s not so simple. 

Fundraising to keep patients in the door

The House has already passed a bill, sponsored by Republican state Rep. Cody Smith of Carthage, that would make it illegal for any public funds, including Medicaid reimbursements, to go to abortion facilities or their affiliates, including Planned Parenthood.

Smith’s bill was also approved by a Senate committee, putting it potentially one step away from the governor’s desk. 

An identical Senate version, sponsored by GOP state Sens. Mary Elizabeth Coleman and Nick Schroer, ran into a Democratic filibuster earlier this year. At a January hearing, Schroer said other health care providers could “pick up the slack” if the law passed.

Since the U.S. Supreme Court overturned Roe v. Wade in June 2022, the Planned Parenthood clinics in Missouri have only provided services such as contraceptives, STI testing, cancer screenings and wellness checks. Missouri’s Medicaid program, called MO HealthNet, serves low-income and disabled citizens, and has long banned funding for abortion, with limited exceptions. 

For the past two years, the Missouri Family Health Council Inc, has informally surveyed the capacity at the state’s safety net clinics, calling to inquire about wait times for new patients. 

The organization found wait times for new patients at the state’s Planned Parenthood clinics averaged between the same day and three days to get an appointment. Across the other safety net clinics, wait times averaged between five and seven weeks, with some clinics as few as two weeks and some pausing new patients completely.

In 2022, across all 68 safety net clinics in the state that take Title X funding, around 24% of the clients were on Medicaid, said Michelle Trupiano, the council’s executive director. She previously testified that Planned Parenthood is the primary family planning services provider for about 20,000 patients across the state.

“Excluding one of the most qualified well known and high volume family planning providers from participating in Medicaid and other programs would have a devastating impact on all safety net providers and patients,” she said. “Safety nets are already stretched too thin, and this would just put a giant hole in the safety nets and at the end of the day, leave clients with a huge gap in access to care.”

Neither Planned Parenthood Great Plains, which oversees clinics in Columbia and Kansas City, nor Planned Parenthood St. Louis Region and Southwest Missouri have received Medicaid reimbursements for the past two years. This is despite winning in court last month, when, for the second time in four years, the state’s highest court rebuked lawmakers’s efforts to ban abortion providers and their affiliates from receiving Medicaid reimbursements through a line in the 2022 state budget.

Medicaid reimbursements are extremely low and contribute to challenges recruiting, Wales said, and retaining providers across safety net clinics. But every dollar makes a difference.

“We have to fundraise to keep the doors open,” she said. “So when you take out any of the resources, even if they’re really small, it absolutely will make it harder for us to provide care.” 

Richard Muniz, interim president & CEO of Planned Parenthood of the St. Louis Region and Southwest Missouri, said such a law would impact their side of the state, too.

“Let’s be clear — Missouri’s safety net cannot keep up without Planned Parenthood health centers, which provide high-quality health care to thousands of patients a year,” he said. “These attacks on care come at a huge cost to our patients’ well-being and the ramifications are felt by all Missourians across the state.”

The Independent reached out to several safety net providers to inquire about their current wait times for new patients. None offered comments. 

Access to care beyond abortion

Maggie Olivia, with Abortion Action Missouri, has been among several Missourians who’ve shown up to Jefferson City to testify against the bills in recent months. 

Olivia used Planned Parenthood as a provider for a decade beginning in high school, continuing after college when she was on Medicaid. She still utilizes Planned Parenthood clinics today even after getting private insurance.

“Being a survivor of sexual violence at a young age makes accessing that kind of intimate care like gynecological care all the more difficult and uncomfortable,” Olivia said. “Planned Parenthood centers are the only place I can consistently rely on to treat me in a respectful and trauma informed way.” 

She said in the years when Planned Parenthood wasn’t an option based on her location, she delayed care because she couldn’t go to the provider she already trusted.

Tara Mancini, director of public policy at Power to Decide, a nonprofit that advocates for access to contraceptives, said bills such as these can also harm access to family planning. 

Birth control is a journey, she said, and patients should have a plethora of options. 

“It’s not enough just to have the pill or condoms or whatnot because that may not work for everybody and their lifestyle and their body,” Mancini said, adding that health centers aren’t required to have a wide range of contraceptives on hand, while Planned Parenthood often offers more options.

She pointed to research out of Texas that found after the state eliminated Planned Parenthood from the state’s Healthy Texas Women program a decade ago, the use of birth control declined significantly. 

According to data compiled by Power to Decide, more than 373,000 Missouri women live in contraceptive deserts, which they define as a place where there’s not reasonable access to a full range of contraceptive methods. Nearly 62,000 Missouri women live in counties that don’t have any health centers that provide a full range of contraceptive methods.

She said bills cutting off Medicaid reimbursements to Planned Parenthood would only further decrease access to contraceptives.

Providers and wait times

Kate Wagner, a family nurse practitioner with the Jefferson County Health Department, a safety net provider, recently saw a patient who came in for birth control. 

The patient had a history of sexual trauma and was nervous to do a full exam. Wagner told her they could reschedule her cancer screening for a day she felt more comfortable, then she filled her birth control prescription and talked her through how a pap smear works. 

Wagner promised that she wouldn’t bother to shave her legs, so the patient shouldn’t feel like she needed to, either. She said in private practice, she might not have been able to afford spending so much time with the patient. 

That personal connection and the ability to spend more time with patients than she might get at a private practice is why she’s stayed.

“My hair may have changed colors in the last 15 years, I may have a few more wrinkles, but I’m the same girl. I have the same corny jokes,” Wagner said. “My patients know me; they know what they’re gonna get.”

She’s a veteran at the health department’s family planning and STI clinic where she splits time between locations in Arnold and Hillsboro, both on the outskirts of St. Louis County. She sees about 25 patients a week, mostly for family planning. If she has to call in sick, the clinic is canceled for the day.

“There are definitely not enough providers to go around,” Wagner said.

Getting a new patient on Medicaid into their door can require “a triangulation of logistics,” she said. While there’s always a physician who can see them, the more pressing question is how soon.

Comfort and continuity is so important, especially for patients who are uninsured and more likely to have a history of trauma, Wagner said.

To limit or close a safety net provider anywhere in Missouri would be “devastating,” she argued, akin to closing a bridge that will have broader impacts on the whole infrastructure, not just those who travel across it.

Johnson, the Arkansas woman who found herself in need of a new provider, is now back with Planned Parenthood on her private insurance. 

In the years since the Arkansas law went into effect, she earned two degrees, became a geologist and turned 40. 

She also took up activism, driving to a few events to tell her story and speak on behalf of Planned Parenthood before the pandemic put her advocacy on pause.

Despite taking a step back from that volunteer work a few years ago, Johnson still thinks about the women across her state who were left scrambling like herself. She hopes they’re OK.

“It’s an utter shame,” she said. “There’s no telling how many women in Arkansas have fallen through the cracks.”