NEW YORK — When Alexis was about 18 years old, she started having mysterious health problems. Her head hurt, her skin broke out. She had trouble with her vision.

Doctors couldn’t figure out what was wrong, and many didn’t take her seriously. Some said her symptoms were all in her head — but not the doctors and nurses at Public Health Solutions.

“This was the only doctor’s office that wasn’t calling me crazy,” she said.

Located in an aging brick building in Brooklyn’s Fort Greene neighborhood, PHS is a family planning clinic specializing in reproductive health care. Alexis first started going there when she was 14, she said, after she was sexually assaulted and needed treatment for a sexually transmitted infection.

But when she started having other health problems, the staff there went above and beyond. They helped her find specialists — and figure out how to get her insurance to cover the visits — until she was finally diagnosed with pseudotumor cerebri, a rare brain condition that required surgery.

Without the care and persistence of the staff at PHS, Alexis said, “I might have died.”

Alexis is just one of the patients who rely on PHS, not just for birth control and STI testing, but also for doctors and nurses who know them and provide them with nonjudgmental, reliable care during what can be a stressful and overwhelming time in their lives. The clinic has been open for over 50 years, and about 3,500 people — most of them low-income people of color from Brooklyn neighborhoods like Brownsville and Bedford-Stuyvesant — walk through its doors every year. It’s one of the only freestanding family planning clinics left in Brooklyn, where patients keep coming back as their families grow and their lives change.

Some patients, like Alexis, now 28 with a toddler, have been receiving care at PHS for more than a decade. Others now have adult children who are patients, too.

But earlier this year, it looked like that might all come to an end. PHS was one of about 4,000 clinics around the country that got funding through Title X, a federal funding program dedicated to family planning. Title X has been in the news in recent months due to ongoing debates over abortion rights, but the funding is meant to help clinics provide services like contraceptives and testing to low-income Americans and cannot be used to pay for abortions. In fact, like many family planning clinics, PHS doesn’t even provide abortions. But if patients say their pregnancies are unwanted, doctors at PHS will refer them to a facility that does.

Left to right: PHS medical director Judith Weinstock, director of sexual and reproductive health services Sarah Blust, and center director Renee Finley on November 6, 2019.
Anna North/Vox

So when the Trump administration gave clinics an ultimatum in August — stop performing or referring patients for abortions, or lose Title X money — PHS chose the latter. Stopping referrals, the PHS board decided, wasn’t an option: The rule “would not allow us to provide the kind of care that we wanted to provide,” Lisa David, CEO and president of PHS, told Vox.

For a lot of patients, “we’re their only source of care and we’re a safe home for them, and they come to us because they trust us,” David said. A regulation that limited the information PHS doctors could give patients “was unacceptable to us,” she added.

However, that decision has had a great impact on PHS’s bottom line, as Title X funds made up almost its entire budget. In August, PHS, which operates the Fort Greene clinic as well as one in Brownsville, sent a layoff notice to 28 employees. Staff also had to tell pregnant patients, who need frequent checkups, to find somewhere else to go for prenatal care, because PHS might not be around by the time of their next appointment.

Patients were asking, “Who do we need to talk to? Where do we protest?” Renee Finley, the clinic’s center director, told me. “It says a lot about these clinics and the people that work at them that these patients were so connected and were so invested in having us here.”

For now, the Fort Greene clinic is keeping its doors open using state emergency funds that expire in March. But the clinic has lost doctors and has had to throw away or return medications — including birth control and vaccines for pregnant patients — because they were purchased with federal money. It’s still not clear what the future holds for PHS and its patients.

The same could be said for many of the nearly 900 facilities around the country that have lost funding as a result of the Trump administration’s rule. With clinics closing or reducing hours, low-income women of color are especially likely to lose access to services like cancer screenings and STI testing.

The fact that this is happening even in New York, a blue state that recently passed legislation that codified the right to an abortion, is a reminder of how easy it is for poor people in America to lose access to reproductive health care, even if that care has nothing to do with abortion. The story of PHS shows that for some patients, reproductive health care is about a lot more than condoms and birth control.

Alexis told me, as her son slept in a stroller by her side, that she had the clinic’s number saved as “Zen” on her phone. It’s so calm here, she said: “Like a temple.”

Public Health Services is a place to get birth control and STI testing — and a lot more

Patients have been coming to the clinic on Flatbush Avenue in Fort Greene since 1965. The area has changed a lot in that time — once a predominantly black, middle-class neighborhood where Spike Lee shot his 1986 film She’s Gotta Have It, Fort Greene has been gentrifying and whitening since the aughts. Across Flatbush from the clinic is Brooklyn’s new City Point development, which includes a Trader Joe’s and an Alamo Drafthouse movie theater.

Now rents are so high in the area that PHS can only afford to stay because it’s located in a building owned by the City Health Department. Most patients don’t live in the neighborhood, though — they come from lower-income areas of South and East Brooklyn. It helps that the clinic is just blocks from the Atlantic Terminal, one of Brooklyn’s largest subway stations that brings in people from all over the city.

Overall, about 3,500 patients visit the clinic every year, with each provider seeing about 22 on any given day. Almost all patients are either uninsured or have Medicaid, said Sarah Blust, director of sexual and reproductive health services at PHS. Most are women, but the clinic sees men and nonbinary people as well.

Though PHS offers a range of reproductive health care services — including prenatal care, STI testing and treatment, and contraception — it does much more. Staff go to local high schools to teach sex education, and the clinics also run tours for teenagers. PHS also offers mental health counseling: up to 12 sessions with a social worker, with a referral for longer-term treatment if necessary. For a significant percentage of patients, the doctors at PHS are the only medical providers they see.

Public Health Solutions lost its Title X funding after refusing to stop referring patients for abortions. The clinic does not perform abortions.
Anna North/Vox
The clinic provides free condoms and services such as STI testing.
Anna North/Vox

When they arrive for their visits, patients find a building that’s more a relic of the older neighborhood than a reflection of the glossy new one. It’s a squat, brick structure that’s definitely showing its age — one of the elevators is perennially out of service. But on the third floor, where the clinic is, light streams through large windows, filling the space where patients check in. In addition to free condoms (the clinic tries to stock Magnums because that’s what teenage boys tend to ask for, Blust said), the waiting room displays pamphlets that explain how to apply for food stamps and other benefits, as well as information about STIs in English and Spanish.

For patients who are nursing, the clinic is outfitting a small nook near the waiting room as a lactation area, with a comfortable chair and a wall painted with butterflies and a flowering tree. Though doctors at PHS don’t provide pediatric care (yet), patients are welcome to bring their babies. Alexis said she brings her son so much, they call him the “office baby.”

In many ways, it was business as usual at the clinic on the day I visited in early November. Desirée, another longtime patient, was there for a prenatal appointment — such checkups make up about 10 percent of patient visits to the clinic. She was 26 weeks pregnant, and her doctor checked her blood pressure and iron levels and discussed the results of her recent glucose test.

Desirée, 27, has been coming to PHS for five years, since she was pregnant with her first child. She heard about the clinic from her mom, who used to be a patient there too. She loves the care she gets at PHS, she told me — her current pregnancy has been a bit different from her first, resulting in a lot of back pain, and the staff here listened to her concerns and reassured her. And though she lives in Bedford-Stuyvesant, not Fort Greene, she appreciates the convenience of the clinic’s location, near where she goes to school for dental technology and just two subway stops from her house.

But like all the pregnant patients at PHS, Desirée learned in August that she might need to find a new doctor.

“I was devastated,” she said. A gynecological exam “is such an intimate type of appointment,” she explained. “I didn’t want to go to just any facility.”

Thanks to a rule change by the Trump administration, the clinic almost had to close

PHS lost its federal funding thanks to a rule finalized earlier this year by the Department of Health and Human Services. Known by reproductive health advocates as the “domestic gag rule,” it bars recipients of Title X funding from performing abortions or making referrals for the procedure. Established under President Richard Nixon, the Title X program is supposed to pay for family planning — contraception, STI testing, and other services — for low-income and other underserved Americans. Providers have long been banned from using the funds on abortions, but under the new rule, they can’t get the money at all unless they pledge not to offer or refer for the procedure.

Most people in the reproductive health community assume the rule was aimed at Planned Parenthood. Before the rule went into effect, Planned Parenthood served about 40 percent of Title X patients, and it has been the focus of “defunding” efforts by Republicans for years. Indeed, Planned Parenthood announced in August that it would leave the program, and at least two of the group’s clinics said they would close as a result.

But the change also affected hundreds of smaller providers around the country. A total of 876 clinics, including Planned Parenthood locations, have lost funding as a result of the rule, according to an October estimate by the reproductive health organization Power to Decide. To cope with the losses, clinics have done everything from reducing hours to cutting services to charging more, “so someone might show up at a clinic and their services might have cost $20 three months ago and now they’re $200, which are out of reach for so many people who rely upon these clinics,” Ginny Ehrlich, CEO of Power to Decide, told me.

Public advocate Letitia James speaks during the Planned Parenthood-organized #PinkOut Day in New York City on June 21, 2017.
Erik McGregor/Pacific Press/LightRocket via Getty Images

Meanwhile, some facilities “are heroically finding and leveraging other funds for the short term,” she said, “but that’s not a sustainable solution for the vast majority of these clinics.”

And some, like PHS, have little to fall back on. After a court ruled in July that the Trump administration rule could go into effect, PHS had appealed to New York Governor Andrew Cuomo for help. But with no assurance that it was forthcoming, they had no choice but to announce its closure in August. Twenty-eight people got layoff notices. Pregnant patients got calls. In mid-August, Kelly Mena of the Brooklyn Eagle reported that PHS leadership was “scrambling to find a lifeline.”

They found it — for now — in emergency funding from the state, which enabled them to rescind the layoffs and keep seeing patients. But while PHS was in limbo — about a week, according to Blust — two of the four doctors resigned. So did one of the nurses and an operations associate who handled inventory and was “the fix-it person around here,” Blust said.

Since getting the state money, PHS has been able to replace one of its doctors. And the two clinics are still fulfilling their mission of treating low-income patients for free, Blust said. But that doesn’t mean everything is fine.

Because of the staff shortage, the clinic in Brownsville is only open two days a week. The clinic prides itself on being able to see people quickly, but staff had to call hundreds of patients and push their appointments back because of a lack of doctors.

Then there’s the issue of medication. Prior to the Trump administration rule, PHS was able to buy medications through a federal program called 340B, which provides medicines at steeply discounted prices to clinics that receive certain types of government funding. Bicillin, for example, an antibiotic used to treat syphilis, cost PHS about $20 a dose under 340B, Blust said — the sticker price is closer to $3,000.

But when it pulled out of the Title X program, PHS lost its federal funding — and its eligibility for 340B. Suddenly it had to pay full price for drugs, which meant it couldn’t always keep enough in stock for patients who needed them.

The clinic ran out of Gardasil, the vaccine for HPV, a virus that can cause cervical cancer, Dr. Judith Weinstock, medical director of PHS, told me.

PHS also ran out of Nexplanon implants, one of the long-acting reversible birth control methods that’s been credited with bringing down the rate of unintended pregnancy — and abortion — around the country. It ran out of Depo-Provera, an injectable contraceptive. It had to throw away TDAP vaccines that protect pregnant women and their babies from whooping cough.

In an especially galling irony for the staff, once they left the Title X program, they weren’t even allowed to use medication previously purchased under 340B — by law, they had to return it or throw it away.

“You have a patient who needs the medication,” Weinstock said, “the medication is 10 feet away and it’s sitting on a shelf that says ‘do not use.’”

For patients, this has sometimes meant difficulty getting the care they need. When the clinic was out of Depo-Provera, Weinstock said, staff sent one patient to a pharmacy to get her dose. But her insurance wouldn’t cover the drug if she got it at a pharmacy rather than a clinic.

Other patients have stopped coming because the clinic doesn’t have the right birth control options in stock, Weinstock said.

When patients stop coming to the clinic, some find other providers. But sometimes, Blust said, “people just might give up on going to someone at all.”

Clinics around the country are feeling the same pressures — and patients could be hurt

Reproductive health advocates around the country fear that the kinds of changes PHS is struggling with could do serious harm to patients’ health — and low-income people of color could see the biggest impact.

“Populations that are already experiencing inequity are most impacted” by the Trump administration rule, Ehrlich, the Power to Decide CEO, said. About 65 percent of people who use Title X services live at or below the federal poverty line, she added. Twenty-two percent identify as black or African American, and 33 percent as Hispanic or Latino.

Cuts to cervical cancer screenings could be especially harmful to Latina patients, who have the highest rates of cervical cancer in America, reproductive justice advocate Estefany Londoño told NBC News. Meanwhile, a drop in breast cancer screenings could disproportionately impact black women, who are more than 40 percent more likely than white women to die of the disease, according to BET.

Renee Finley, center director, works at her desk at PHS on November 6, 2019.
Anna North/Vox

And in some cases, cuts to Title X funding could mean the difference between seeing a doctor in a given year and not seeing one at all. “For some people, that care from Title X clinics [is] the only care they get,” Ehrlich said. Providers there often check their blood pressure or perform Pap smears or breast exams, she explained, meaning a whole range of basic preventive health services “have been eliminated from the safety net in addition to access to contraception.”

To predict the possible impact of the Trump administration’s rule, many reproductive health advocates point to Texas, where the state legislature slashed family planning funding by more than half in an effort to target Planned Parenthood. Eighty-two clinics closed or cut family planning services as a result of the cuts, and in counties that lost Planned Parenthood clinics, the percent of patients getting IUDs and other long-acting reversible contraceptives dropped significantly, as Joseph E. Potter and Kari White, who conducted research on the impact of the cuts, wrote in the Washington Post. In one survey, patients reported difficulties finding a new provider and being charged unauthorized co-pays when they did.

New York isn’t Texas, to be sure: “I have one of the most pro-public health and women’s health governors in the country,” David said. But the fact that clinics here are struggling is a reminder of how far-reaching the effects are of the Trump administration’s rule.

Many blue states, including New York, California, and Hawaii, are stepping in to replace some of the federal funding lost after the rule change, as Marie Solis reports at Vice. But advocates say that puts a burden on state budgets.

Even New York is “facing a very significant budget deficit” right now, David said. “We’re up against a challenge to continue to get funding.” The current grant from the state runs out in March, and if it’s not renewed, she said, “I can’t continue to operate these sites.”

For patients, that’s a frightening prospect. “We need these type of places,” Desirée said. She recently referred one of her cousins to the center. Desirée’s message to lawmakers around the country: “Please don’t close this place!”

For Alexis, “this is one of the places that keeps me living,” she said. Thanks to the persistence of the PHS staff, she had brain surgery in 2015 and is now near the end of a multi-year recovery process. She graduated from college in 2017 and is currently applying for disability assistance.

Alexis hopes to get care at PHS for years to come: “They’ll never make me leave,” she said. If she ever has a daughter who’s old enough to need reproductive health care, she said, “I’ll bring her here.”

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