Health care reform is the hurricane of U.S. public debate this year. Within that debate, access to abortion has been smack dab in the eye of the storm. Pro-choice advocates are outraged that legislators have sought to strip us of our ability to retain private insurance coverage for abortion services. But what of the women who never had that coverage in the first place? What about the low- income women in our country who, because of the Hyde Amendment (now considered to be “abortion neutral” so to speak), never had equal access to abortion? Where do these women go when they need or want an abortion in this country?

If you said Planned Parenthood, you’d only be partially right. In some parts of the country, the majority of abortions and much of the family planning services are actually provided by independent, non-profit, feminist women’s health centers. Health centers that have been in continuous existence for upwards of 30 to 35 years.  Health centers that provide the kind of woman-centered, non-judgmental, empowering care so critical for abortion and other reproductive health related services.

Lower and middle-income women have relied upon these independent, non-profit community health centers for years for abortion, birth control and annual exams. Sure, we think about these clinics when a provider like Dr. Carhart or Dr. Tiller is targeted, injured or killed by anti-choice terrorists. We talk around them, discussing the lack of access to abortion care, the problems with forcing women to view ultrasounds, how many providers are left in this country and where they are located, how much it costs for a woman to have an abortion, and how far she has to travel.

But how many of us actually think about our country’s original basic reproductive health service providers, the architects of the movement for informed, empowered, self-directed health care? These centers and the women who staff them (many of whom have been there for 15, 20 and 25 years) are pioneers quietly existing, on the periphery of our awareness; struggling for the funding and resources necessary to continue providing optimal care to mostly lower- and middle-income women in this nation. What many don’t realize is that most, if not all, of these health centers are not solely abortion providers. These community centers engage in extensive outreach, community education, provider education and training, family planning services including contraception, HIV/AIDS testing and more.

We can do all of the lobbying, grassroots advocacy and activism in the world but in the end, if we don’t have providers and centers to provide women with quality abortion care and related health services, what’s the point?

Back in 2007, I wrote a two-part series entitled, “Life Support for Feminist Health Care?”, during the closure of Aradia Women's Health Center, the 34 year-old, non-profit, women’s health center at which I worked for seven years. The center, like all of the original feminist health centers in this country, opened its doors in response to community need – i.e., responding to what women, immediately before and after abortion was legalized, needed and wanted but weren’t getting in terms of reproductive and sexual health services. You could say feminist health centers were (and continue to be) both political and health care related ventures, for sure.

At that time, with Aradia Women's Health Center closing its doors due to rising numbers of low-income women as clients with little or no insurance coverage, decreasing Medicaid reimbursement, as well as the continued difficulty of finding funding streams, and only fourteen independent, abortion-providing, feminist health care centers in a similar boat remaining, I was feeling rather hopeless that these centers would live on.

In 2007, I wrote, “…it is astonishing that so many still don't recognize the feminist women's health movement's many contributions to the healthcare landscape in general and to women's lives in particular. It's a shame, because it seems that we may be heading toward the end of an identifiable era of great value to women in America.” After speaking with two amazing women who have been doing this work for a combined total of 33 years, both of whom have been integral to the creation of what’s now called the Feminist Abortion Network (FAN), a network of these remaining independently operated, feminist health centers, I am more convinced than ever that there is hope on the horizon for feminist health care and the non-profit health centers that keep feminist care alive and well, if we can address some key issues within health care reform, namely Medicaid reimbursement and the importance of a public option to ensure that all Americans receive coverage for care.

Kudra MacCaillech of Concord Feminist Health Center in New Hampshire and Joan Schrammeck of Cedar River Clinics in Washington, both agreed to speak with me about the formation of FAN, what it’s like keeping independent, feminist women’s health centers alive and viable and their hopes and dreams for the future of feminist care in general.

Kudra and Joan have coordinated their respective feminist health center’s development, outreach and communications activities for more than 15 years – one on the East Coast, the other on the West Coast. Both organizations have been on the front lines providing abortion and many other reproductive health services over 35-years.

Why did FAN form?

KUDRA:  About five years ago, leaders in our feminist women’s health centers (FWHCs) from various parts of country started reaching out to each other, engaging one another in ideas and dreams for our future.   Though we weren’t strangers (some of us were acquainted through regional or national initiatives) we didn’t really consider ourselves “connected.”

I can’t say what inspired the “click” to connect, but that’s exactly what it felt like.  It was exciting, but also very focused and coordinated.   Initially, we were brainstorming ways to collaborate on projects and funding; projects that had not only the potential to impact the clinics in our own states and communities – but every FWHC across the entire country.

Oddly, even we weren’t sure how many centers remained or where we were located. So, the next logical step was a census of FWHCs in the U.S.  We sought out clinics that were nonprofit, feminist in roots and philosophy, independent of a larger corporate or institutional umbrella and were committed to providing abortion services.

It is worth mentioning how struck we were by the number of FHWCs that over the last decade either closed or were left with no viable alternative other than merger.  In this relatively short span of time, FWHC’s ceased operations in Burlington, VT, Tallahassee, FL, Philadelphia, PA, and Eugene and Portland, OR.  [Ed. Note: At FAN’s formation, Aradia Women’s Health in Seattle, WA and A Woman’s Choice Clinic in Oakland, CA were operating.  Both centers have since closed their doors.]

Through this exercise of identifying the FWHCs, we discovered that despite our organizations operating totally independent of one another, we were remarkably similar in structure, philosophy and not surprisingly…challenges. As the group began to take shape, it became clear that collectively, we possessed an enormous amount of experience, expertise and resources - we were all on the forefront of social and reproductive justice efforts in our states and regions.

Tell me about feminist health centers and what you hope to accomplish with FAN.

JOAN: Each of our FWHCs has long been committed to notion that independence is the best way to ensure responsiveness to our community’s needs. We also firmly believe that ultimately, it will be our independence that ensures abortion services remain affordable and accessible to women in communities across the country.

Safe, compassionate and professional abortion services will remain a top priority in our mission and services. In the years after Roe v. Wade, in true grassroots feminist activism, without waiting for someone to give them permission– each of our organizations was founded by local women who saw a need and said, “Let’s start a clinic.” Our priority and promise today is the same as it was nearly 40 years ago.  For all FAN clinics, women’s autonomy and right to abortion is simply not up for negotiation.

Kudra: And, in practical terms, FAN is our conduit for connection.  It celebrates our independence at the same time it supports and encourages our interdependence.  A major focus for this group is sharing resources and information among members, whereby building stronger, more effective and responsive FWHCs throughout the nation.  And of course, in working together we can be that much more effective in our work informing public health policies, challenging legislative and regulatory attacks on women’s rights, educating in our communities, contributing to the national pro-choice conversations and agenda and perhaps most importantly, raising the voices and experiences of the women who need and deserve our care.

In current health reform discussions, we hear about the fact that for many providers (not just abortion providers), Medicaid reimbursement is too low to maintain providing care for lower income Americans. How do you all do it and remain viable?

Kudra: In terms of Medicaid and abortion coverage, it cannot be overstated how acutely low-income women, struggling single mothers, women of color and young women and feel the injustice of the Hyde Amendment’s ban on coverage for abortion care.

It is for this very reason that that FAN members uphold a commitment to never denying a woman an abortion for lack of resources and maintain internal women-in-need-funds.  For decades FAN clinics have been waiving and reducing fees, collectively accounting for hundreds of thousands of dollars in subsidized health care costs each year.  We do so with the support of outstanding organizations like the National Network of Abortion Funds, and of course, generous individuals and foundations.  Even still, there is a significant unmet need and one that will only become more problematic, should Congress restrict or deny coverage in the final health care reform package.

Joan:   Beyond abortion care, there exists a huge challenge in making a nonprofit successful when the majority of its clients are Medicaid recipients.  But with that said, I believe that the nonprofit model of health care is the best option for the whole nation.   Primary care should be not-for-profit.

The whole country is looking at this question – where is for-profit care taking us? It’s already brought about this chasm so that the wealthy people have insurance and low income people, women needing reproductive and sexual health care, don’t get it and need to reach into their pockets to access care or go without.  Our nation and current health care reforms should be moving more towards the feminist model of health care delivery.  This would look like:

• Sharing information in a safe, supportive environment.
• Ensuring that every client has the opportunity to have all her/his questions answered so they may give genuine informed consent.
• Facilitating empowered decision making (A.K.A. the client knows her/himself best and is capable of making good decisions, if given accurate and unbiased information).
• And, something that is all too rare in health care these days, taking as much time as each person needs.

Kudra: I have thought about this question a lot, and as Joan points out, we believe that the nonprofit and feminist model is a just and humanitarian approach.  And I wonder if it were widely accepted and adopted, if we would find that when people are engaged in the decisions that affect them, and are trusted in the choices they make for themselves, and are given real options, support and compassion, there would be enormous health care savings.

For now, I’m not sure that the business struggles of small feminist health centers are much different than any small health care provider trying to remain independent in this climate.  In this way, we’re not unique; there are hosts of challenges that private physician practices or clinics must overcome in the face the corporatization of heath care.  In my state for example, there are very few independent OB/GYN or Family Practices physicians able to remain competitive and similar to FWHCs, are often left with no option but to close or merge with larger institutions.

It makes me think about the idea of diversity in health care delivery; the value we place on people having more than one option for where and how to receive care if they are consumers, or provide the care if they are health professionals.  Perhaps we might think of this in the way that we think of biodiversity.  Why is biodiversity to crucial?  Because we know there are significant negative consequences when a species is lost, and that once we lose it, there is high improbability that we will ever get it back.

I think there is a critical role to be played by the diverse and distinct types of providers we still have in our “health care ecosystem” and that we should consider what might be the consequences of their disappearance and absorption into the corporate conglomerate.

Joan, if one out of three women in this country have abortions, why do we continue to see such vicious anti-choice legislation on the table? Why don’t women who have had abortions speak up more?

Joan: The stigma that the anti-choice people have put on abortion through years and years and years of horrible, ugly picket signs, calling abortion doctors murderers and then actually murdering doctors has really put a stigma on anything having to do with abortion. And the pro-choice side continues to search for a unifying message and theme to reclaim the moral position as well as to integrate abortion into the full realm of women’s experiences. It’s important to repeat the statistic that one out of three women will have an abortion in this country.  Eighty-five percent of women will get pregnant and have a baby. Everything about pregnancy belongs to woman. Abortion is one of the paths she might choose but that it’s her decision.

Have you seen a change in who is accessing the care you provide over the years?

Joan: Most of the women who access abortion are young – in early adulthood, between twenty and twenty-five years old. They don’t necessarily have insurance or a full time career path type of job so they are more than likely reaching into their own pockets to pay for care (including annual exams, STI testing and treatment, birth control and family planning). The change, we’re seeing, is that it’s more and more lower income women who are coming to our feminist community clinics.

All of our FAN clinics have the reputation as compassionate safety net providers.  As a result, we are also seeing a new trend in large numbers of resettled refugee and immigrant women referred to us.  We believe that language shouldn’t be a barrier to care, and so next year, Cedar River Clinics budgeted $70,000 in interpreter fees alone.  This is a concrete example of the feminist model of care - - and it is this sort of responsive and responsible approach that we hope to see in the health care reforms.

We hear often that there are dwindling numbers of medical students or younger providers willing to provide abortions. Is this true and what can we do about that?

Joan: In terms of the mid-pregnancy, fetal anomaly services that Dr. Tiller provided and Dr. Carhart continues to provide, yes, there is a shortage of people willing to take on those responsibilities. As rare as those abortions are, we need them in more than one place in country.
In addition, because public health clinics are closing due to state and county budget cuts, we will see more women for both abortions and for preventive, routine well-woman care and birth control. In fact, we are planning in Renton to start offering walk-in well woman care next year to make it more easily accessible.

Is there anything else you both would like to mention?

Joan: It’s a value of our organizations to retain our independence from hospitals or universities or other institutions, because that is how we retain our dedication to our local community, to the needs of local women. We worry that if we chose to merge with some other larger institution, abortion services would be the first thing to get cut. We are here, first and foremost, to serve the women of our communities. Through FAN we strengthen each of our organization’s abilities to thrive.

Kudra: I totally agree. We knew that in discovering each other again, were holding something special and quite possibly, something irreplaceable in our hands.  Something that with a little wit and will, has the capacity to ensure not only that our clinics thrive, but that the feminist health agenda is advanced nationwide.

Rather than contracting in the face of our challenges, we’re choosing to clasp hands and expand. It’s just so exciting to be part of a renaissance happening within our reproductive justice and feminist movements.

2010 FAN Members:

Blue Mountain Clinic - Missoula, MT est. 1976

Boulder Valley Women’s Health Center - Boulder, CO est. 1973

Cedar River Clinics – Tacoma, Renton & Yakima, WA & est. Aug. 1979

Concord Feminist Health Center - Concord, NH est. Oct. 1974

Emma Goldman Clinic - Iowa City, IA est. Sept. 1973

Feminist Women's Health Center - Atlanta, GA est. 1977

Feminist Health Center of Portsmouth - Portsmouth, NH est. 1980

Feminist Women’s Health Centers of California - Chico, Redding, Sacramento & Santa Rosa est. Feb. 1974

Mabel Wadsworth Women's Health Center - Bangor, ME est. 1984

Memphis Center for Reproductive Health - Memphis, TN est. 1974

Midwest Health Center for Women - Minneapolis, MN est. Sept. 1975

Preterm - Cleveland OH est. 1973

Women’s Health Center of West Virginia - Charleston, WV est. 1976

Women's Health Center PA - Duluth, MN est. April 1981

For more information on the Feminist Abortion Network or to find a clinic near you, visit the FAN site.