DEXTER, Maine — The Trump administration’s effort to restrict abortion at federally funded family planning centers is about to hit home in parts of New England, where far-flung clinics that serve the rural poor face the threat of cutbacks or closure.
The closing of clinics in remote towns would make it harder for low-income women to get not just abortions but also birth control. Maine’s network of family planning providers has warned that in the worst-case scenario, it could be forced to close most of its health centers, leaving large swaths of one of the most rural states in the nation with no such clinics.
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“It would be heartbreaking to me to see people in this community that won’t be able to access care like this,” said Christy Suvlu, nurse practitioner at Dexter Family Planning, the clinic in this rural town about an hour northwest of Bangor. Patients range from teenagers to small business owners who find insurance coverage prohibitively expensive and instead pay for care on a sliding scale.
“It just makes everything much easier for them, getting their basic reproductive health taken care of and preventing pregnancy,” Suvlu said.
The changes stem from a new rule for the federal Title X program issued by the Trump administration that aims to disentangle abortion services — which can’t be funded with federal dollars — from family planning programs that can. The new rule is a response to longstanding concerns by abortion opponents who see the family planning money as an indirect subsidy for abortion. Clinics that provide both would have to physically separate their abortion operations, potentially requiring renovations or new facilities.
And, even if they stopped providing abortions, clinics could no longer tell their patients where else to turn. Suvlu, for instance, wouldn’t be able to tell a pregnant woman that abortion is available at a clinic in Bangor.
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Nationally, the best-known provider of family planning is Planned Parenthood, but in Maine, a nonprofit called Maine Family Planning manages the federal funding for Planned Parenthood and numerous other health centers and schools, and operates 18 clinics of its own. Like Planned Parenthood nationally, Maine Family Planning recently pulled out of the Title X program, rather than adhere to the new restrictions. For Maine Family Planning, that meant giving up about $2 million a year.
The Maine nonprofit also challenged the rule in federal court, saying it could “undo decades of progress for the health of those most in need” and have “devastating effects on the state of Maine.” The state currently has a low rate of pregnancies among teenagers and, a recent analysis found, the nation’s highest rate of contraceptive use among those at highest risk of unintended pregnancy.
Complying with the new rule would have forced Maine Family Planning to stop providing abortions at 17 of its 18 health centers, leaving just three centers statewide where new patients could get an abortion, according to the lawsuit. Currently, there are 20 such centers.
But Maine Family Planning said that even if it could afford to separate its abortion and family planning services, it would not do so because it would be unethical to withhold information about abortion from patients.
Maine Family Planning said it has gotten signals that the state’s political leaders will step in to fund the difference — as Governor Charlie Baker and the Legislature did months ago in Massachusetts — but that probably couldn’t happen before spring, said Evelyn Kieltyka, senior vice president of program services at the nonprofit.
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But more than 27 percent of the nonprofit’s budget comes from the federal Title X program, and if the funding isn’t restored in the long run, Maine Family Planning could be forced to close or cut back services at 11 to 15 of its health centers, the group said in its lawsuit. It might also have to end services it provides through other health centers.
The result would be devastating to the people of Maine, “many of whom have no other access to health care, much less to family planning services,” the nonprofit’s lawsuit said. Some of Maine Family Planning’s clinics are as far north and east as the Canadian border, making travel to alternate clinics in southern Maine cities prohibitive. Poverty, lack of health insurance, and unpredictable driving conditions create additional hurdles for Mainers to travel for care, the suit says.
The loss of a clinic would hit especially hard in Dexter, a tiny town of 3,800 nestled in the Maine Highlands with an aging population that voted overwhelmingly for Donald Trump in 2016. Dexter still hasn’t recovered from the loss of its largest employer nearly two decades ago; even its town manager describes it as “struggling.” The metal husk of the Dexter Shoe Co. factory, which employed 800 before the company was bought by Warren Buffett, now accommodates just a few dozen workers handling shoe distribution and returns. The shuttered old mill now houses adult education classes.
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Low-income patients who qualify for MaineCare — the state’s Medicaid program — will still be able to get birth control through doctors’ offices, hospitals, or other federally funded clinics, and patients covered by the Affordable Care Act still receive free birth control, for now, despite Republican efforts to alter it.
But the family planning centers now being affected have, for decades, been the place to turn for confidential, nonjudgmental treatment for sexual preventive health, sanctioned by a federal government that considered it a public good. A patient who comes in for a chlamydia test won’t be turned away if she can’t pay the fee; a payment plan is permitted. The clinics dole out several months’ worth of birth control pills at once, recognizing such conveniences help women stay on track.
Title X is intended to make contraception readily available to anyone, including low-income patients, immigrants, and rural residents who might otherwise lack access. The US Centers for Disease Control and Prevention recognized family planning as one of the 10 greatest public health achievements of the 20th century. In Dexter, 28 percent of patients at the clinic receive services funded by Title X.
“This program has been around since the ’70s, and it was Richard Nixon who signed into law, and one of the champions was George H.W. Bush,” Kieltyka said. “It was ‘the right thing to do.’ ”
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Not everyone agrees — particularly in a conservative town such as Dexter, where some still see stigma hanging over the family planning clinic. Inside Our “FAMB”ily Restaurant (named for the first initials of the members of the family that owns it), the regulars often grumble about abortion and Planned Parenthood, said 20-year-old Ashley Reynolds, the “A” of the family and a liberal outlier in town. In high school, when students solicited local businesses for fund-raisers, they were urged to steer clear of the clinic, she recalled.
Her mother, Melissa Reynolds, said visits to the clinic are kept mostly “hush-hush” because of the dual implications of sexual activity and poverty. Still, she acknowledges, “When I was 15, that’s where I went to go get birth control. If you’re having sex and you can’t talk to your family about it, then that’s the best place to go.”
Not all patients come to family planning clinics for sex-related concerns, of course. Rosemary Polichak, a 64-year-old retiree, had an appointment last week for her annual checkup and Pap smear. She started going to the clinic for birth control in the 1970s, before she had children, when money was especially tight, she said. She keeps going back for the familiar.
“I always knew the people. And they didn’t change doctors every other day,” she said.
Other recent walk-in patients included a 20-year-old mother who thought she was pregnant again. (She wasn’t, but Suvlu educated her about birth control options and screened her for STDs.) Another was a woman who had been bounced out of MaineCare because she failed to fill out the paperwork after she turned 19.
Last week, 16-year-old Lilah McCormack dashed into the clinic after the first day of school and before field hockey practice to pick up her birth control pills.
“If this wasn’t here, it would be a lot harder for me to get,” she said, noting she was borrowing her mother’s car. “I couldn’t drive an hour just to get my birth control or get tested.”
A junior at Dexter Regional High School who has six siblings, McCormack said she started coming to the clinic secretly last year, but her mother later found out and supported her decision. She encourages friends who are sexually active to take advantage of the clinic, recommending regular STD screenings there.
“I’m just that friend,” she said.
“It’s just hard to imagine not having something as accessible as this, ’cause I’ve had it for a while now,” she said. “And I don’t know, I just can’t imagine how bad it could be for people that had it worse than I do.”
Stephanie Ebbert can be reached at Stephanie.Ebbert @globe.com. Follow her on Twitter @StephanieEbbert.