A renewed spotlight on protecting access to birth control may not help women who are already struggling to find affordable contraception in some states with the strictest abortion laws.

At a family planning clinic in Tuscaloosa, Alabama, that largely helps low-income women, executive director Robin Marty has to make sure the clinic, WAWC Healthcare, has a variety of contraceptives on hand, including pills, patches, implants and IUDs, so patients can get free or low-cost birth control during their appointments.

It’s something that has become increasingly difficult to do in Alabama, along with other rural Southern states including Mississippi and Texas.

“The vast majority of our clients are people who are at or below the poverty line. Most of them are Black women, and many of them have no primary care provider. They come in to us in order to access contraception,” Marty said.

Years before the Supreme Court’s Dobbs decision overturned Roe v. Wade, policy changes, flatlined funding and shuttering clinics put a strain on small family planning providers that have to fund the upfront cost of stocking a range of contraceptives, from birth control pills to injections to intrauterine devices, for their patients. That can reach around $30,000 for a clinic that dispenses birth control to about 50 to 75 patients a month, said Kate McCollum, senior director of the Trust Her initiative at the Child Poverty Action Lab in Dallas.

Federal regulations require states to cover contraception for Medicaid recipients, but states get to decide which types are covered. It can also be difficult to qualify. For example, in Mississippi, a single woman who is not pregnant cannot make more than about $20,000 before taxes to qualify for Medicaid.

Having birth control on hand is important. If a clinic doesn’t stock a person’s preferred method of contraception, they often don’t return, said McCollum.

“We see that especially for people who are low income, finding child care, transportation, taking off work is just not feasible,” she said.

Few community clinics have the amount of money needed to cover birth control each month, McCollum said. Even if they do, “you’re taking a risk by stocking them because you might not be reimbursed.”

Closing clinics puts strain on those that remain

There was hope that when the Food and Drug Administration approved the first over-the-counter birth control pill in 2023, the $20-a-month cost would help. Opill is stocked at stores nationwide, including certain Target, Walmart, Walgreens and CVS locations.

But over-the-counter birth control pills haven’t reached many women in rural areas. They “are often lucky if they have a grocery store in their town,” Marty said.

In such rural places, residents “don’t have broadband, the mail delivery doesn’t always show up,” said Marty. “I can’t reiterate how important it is that everything be in a person’s hands during a face-to-face appointment.”

In Mississippi, it’s common for women seeking a clinic to travel two hours for an appointment, said Jitoria Hunter, vice president of external affairs at Converge, a nonprofit that allocates federal funding for family planning services in Mississippi and Tennessee.

The latest report from the Center for Healthcare Quality and Payment Reform, a nonprofit that advocates for improvements in health care payment and delivery systems, found that more than 40% of hospitals in Alabama, Mississippi and Texas, as well as neighboring Louisiana, Arkansas and Oklahoma are at risk of closing due to financial strain, adding to the shortage of family planning care.

In many cases, these closures are the result of policy changes that eliminated one very important source of funding: Title X family planning grants.

Title X plays a major role in funding family planning services for women living near or at the federal poverty level, including birth control and preventive health services such as Pap smears. Each state decides which clinics receive this funding. In 2011, in an effort to divert funds from Planned Parenthood, Texas legislators voted to exclude any clinic associated with an abortion provider from Title X grants. That meant that even if a clinic did not perform abortions, if it was associated with one that did, such as a Planned Parenthood in another state, it could not receive the funding.

Because of the Texas policy change an estimated one-quarter of family planning clinics in the state closed by 2013.

In Texas, “the Title X clinics have had flat funding for years. It’s not enough to meet demand,” McCollum said.

In Mississippi, the state with the highest teen and preterm birth rates and the second-highest maternal mortality rate in the nation, “the Title X grant is not enough to cover taking on those patients since hospitals have closed or are significantly in the red with seeing patients,” Hunter said.

Even with deep discounts provided by the federal 340B subsidized drug pricing program, clinics face paying tens of thousands of dollars to stock birth control without a guarantee of Medicaid, insurance or cash reimbursement. Private insurers may also not cover IUDs, which can cost as much as $1,300, according to Planned Parenthood.

“If we have a patient that comes in who is on Medicaid and they want to get a Nexplanon implant, we have two options,” Marty said. 

The first is buying the device, a small rod implanted under the skin that slowly releases hormones for up to three years, at the full price of about $1,200, which Medicaid does not always reimburse, and may not reimburse in full. Alabama, Texas and Mississippi are among the 10 states that voted not to expand Medicaid this year, meaning it remains difficult to qualify.

The second option is getting the implant through the 340B program, which Marty said costs about $500. Even with that discount, many of her low-income patients can’t afford it.

“So either way, we’re out money,” said Marty.

When government programs fall short, a handful of nonprofits have stepped in to help clinics provide free or low-cost contraceptives. In Texas, the Trust Her initiative has subsidized 20 clinics in Dallas County with grants to cover a month’s supply of birth control.

“If someone does not have insurance, we can pay for their visit and their birth control method,” McCollum said. “If they have Medicaid or private insurance, they can pull from that stock when the patient is there and then get reimbursed.”

The nonprofit group has funded Comadre Telemedicine in Dallas, covering the cost of patient visits and their birth control. Micaela Sanchez, a women’s health nurse practitioner and founder of the Dallas clinic, became a parent at 17 years old, so the mission to stock every type of birth control someone may want is personal for her.

Because it’s not a Title X clinic, Sanchez can counsel minors about contraceptives without parental consent, but it also means she doesn’t have access to that source of funding.

“The reason I’m able to do this is because of Trust Her covering the cost of patients getting same-day options,” Sanchez said.

Plan A, a free community clinic in Louise, Mississippi, that also runs a mobile clinic in the Mississippi Delta and a forthcoming clinic in Georgia, can’t afford to have all forms of birth control it offers patients on hand at all times.

Meta Anderson, a nurse practitioner at Plan A, recently put in an order for Nexplanon for a patient in her late 20s who works as a hairdresser and does not have health insurance. She came to Plan A after being unable to get the contraceptive implant through her primary care provider. The provider, a federally qualified health center, charges patients a sliding-scale fee.

“She would have to pay a fee to be seen, and then she would have to pay for the implant,” Anderson said. “She doesn’t have the funds to pay for this out of pocket.”