Clinics Caught in Conflict of Abortion Rules

In the two weeks since the U.S. Supreme Court upheld regulations barring abortion counseling in federally funded family planning clinics, health officials in California have been exhaustively exploring how they might survive the ruling, which they say could cut off family planning services for a quarter of the state’s women who need them.

The effort has bewildered clinic operators and their lawyers, as they have slogged through a morass of conflicting state and federal mandates and grimly considered the consequences of their choices.

Among strategies under consideration are new legal challenges to block implementation of the ban, first proposed by the Reagan Administration in 1988 but tied up in the courts until the Supreme Court’s 5-4 ruling May 23. Clinic officials are also searching through the high court’s decision for a loophole that would permit them to accept federal money and still inform pregnant women of the abortion option.

There is strong consensus among clinic operators that abiding by the ruling would violate their professional mission. “We have 12-year-olds coming in here who are pregnant,” said Silvia Drew Ivie, executive director of T.H.E. Clinic for Women in the Crenshaw neighborhood. “We are not simply going to say, ‘Hi, you’re pregnant, good-by.’ ”

In the meantime they are hoping--and lobbying--for swift action by Congress to overturn the counseling restrictions.

Finally and reluctantly, they are calculating the impact of forfeiting the roughly $12 million that clinics in California receive under Title 10 of the U.S. Family Health Act. That may be the only way to continue to do abortion counseling under the ruling.

“The consequence would be severe,” said Thomas Kring, executive director of the Los Angeles Regional Family Planning Council, the distributing agency for Title 10 money in California through its subsidiary, the California Family Planning Council. “Hours would be shortened, and fewer women would be seen. Easily 100,000 women of the 400,000 who now receive Title 10 services in California would not be seen without additional funds from the state.”

Specifically, the high court upheld regulations that prohibit federally funded clinics from mentioning abortion as an option to pregnant women or referring them to abortion services. Counselors would be permitted to only talk about bearing the child to raise or relinquish for adoption.

Final rules issued by the U.S. Department of Health and Human Services implementing the restrictions are not expected to take effect until late summer. Family planning activists say they will devote the interim to blocking the rules.

Meanwhile, Kring said, clinics in California are continuing business as usual--providing abortion counseling as part of the standard array of options presented to pregnant women or those seeking pregnancy testing.

“We are telling the clinics, ‘Don’t do anything different until you hear from us,’ ” he said.

Of more than 400 family planning clinics in California, 218 receive federal money commingled with state funds distributed by the family planning councils.

Turning down the federal money is a bitter--and financially difficult--choice for those who believe their clinics even now fail to reach many women in need of contraceptive services, pregnancy testing and counseling.

It is also legally problematic. Many clinics receive the federal and state money through a single contract with the family planning councils. Would these contracts have to be redrawn if clinics reject the federal money?

That is one of the many procedural questions the family planning council’s lawyers are studying, according to council spokeswoman Sima Michaels.

A complicating factor is California law, which specifically requires that clinics accepting state funding--and all of those receiving Title 10 money do so--include abortion as among a pregnant woman’s options.

For clinics to retain both sources of funding, the state would have to amend the contracts to void its own insistence on abortion counseling.

“I think that is very unlikely,” said Elizabeth Brandt, chief legal counsel to the California Department of Health Services.

“It is a real Catch-22 for us,” said Alicia M. Thomas, executive director of the East Valley Community Health Center in West Covina, whose family planning clinic serves 4,000 low-income women in the San Gabriel Valley.

About 39% of the clinic’s $200,000 family planning budget is Title 10 money. Thomas has little hope of replacing that through private fund raising or higher patient fees. She tried approaching foundations for additional grants two years ago when Gov. George Deukmejian slashed the state family planning budget by two-thirds. But grants “simply can’t fill the gap,” she said.

Pressured by fellow Republicans, Deukmejian allowed a bill restoring most of the money to become law. But 40 clinics across the state closed during the six-month budget battle, and many others shortened their hours.

Kring of the family planning council said he does not think loss of Title 10 money would force any California clinics to close. But Thomas worries about the impact of service reductions or reduced hours on the women served by the East Valley clinic.

“We do not treat a sophisticated population here,” she said. “Some of these women just don’t know what their alternatives and choices are.”

Planned Parenthood of Los Angeles, which operates 10 clinics in Los Angeles County serving 40,000 family planning patients annually, found in a survey of its clients that 34% had less than six years of education and the vast majority live in poverty, unable to afford private medical care.

The taxpayer-subsidized family planning clinics are, for many of these women, the only source of services such as screening for cervical and breast cancer, in addition to contraceptive and pregnancy information.

Dr. Joan G. Babbott, Planned Parenthood’s executive director, said forfeiting nearly $300,000 in federal funds it now receives would mean dropping at least 3,000 of the 10 clinics’ patients--but as a physician she said she sees no alternative.

“Who are these lawyers, these Supreme Court justices, to say to me, ‘Here is a woman with a pregnancy that is very dangerous to her health, but you can’t mention abortion?’ ” Babbott said angrily.

Overall, 79 clinics in Los Angeles County operated by 23 family planning agencies receive a total of $2,881,307 in Title 10 money. Nearly a quarter of these funds contribute to the operations of 42 clinics run by the Los Angeles County Department of Health Services. Dr. Ellen S. Alkon, the department’s medical director for public health, said she also is conferring with lawyers on what to do about the Supreme Court ruling.

Beyond Los Angeles County, nearly $7 million in Title 10 money also subsidizes care at 139 clinics operated by 47 additional family planning agencies throughout California. The California Family Planning Council uses the remaining $2.3 million of California’s $12 million federal allocation for administrative overhead.

Thomas of the East Valley clinic is one of many family planning officials who say they are counting on Congress to void the restrictions. Failing that, she said she will forfeit the federal money rather than comply with the restrictions, hoping for an additional state subsidy to offset the loss.

Other clinic directors also are looking to Sacramento for a way out of their funding dilemma. Gov. Pete Wilson has pledged to try to offset any financial harm to California family planning programs resulting from the Supreme Court decision.

But the state’s estimated $14.3-billion budget shortfall looms over Wilson’s promise, making clinic administrators nervous about counting on it. Because the state provides about 75% of the public money for family planning, turning down state funding--and its legal mandates to counsel women on abortion--in order to comply with the federal rules does not make great financial sense.

Moreover, most family planning professionals consider the abortion counseling restrictions to be an untenable curb on their obligation to provide complete information to patients, according to Judith DeSarno, executive director of the National Family Planning and Reproductive Health Assn., a Washington-based trade group representing about 90% of the nation’s federally funded family planning clinics.

“It is basically lying by omission,” said DeSarno, whose organization is leading the lobbying effort for several bills in Congress that would void the abortion counseling ban. “Most of our health-care providers will not work in a way that compromises the quality of care of patients,” she said.

The association, which officials of California’s family planning councils say is advising them on strategy, also is exploring whether clinics could legally get around the federal rules by separating the use of federal, state and other money in the clinics. That way, pregnancy and contraceptive counseling--in which discussion of abortion generally arises--could be shown to be supported by non-federal funds.

Brandt, the lawyer from the California Department of Health Services, said she believes the Supreme Court decision clearly prohibits such reclassification. But it may permit clinics to operate with actual physical separation of federally funded and other services. For example, abortion counseling possibly could take place under the same roof, but accessible through a separate entrance, she said.

While the lawyers study these possibilities, DeSarno’s organization, the Planned Parenthood federation and groups such as the American Medical Assn. and the American College of Obstetrics and Gynecology, are pushing Congress to explicitly mandate abortion counseling as a condition of accepting Title 10 money.

This would alter the impact of the Supreme Court decision, which technically upheld the right of federal agencies to restrict the use of federal funds in the absence of instructions to the contrary from Congress.

Senate Bill 323, introduced by Sen. John H. Chafee, (R-R.I.), would amend Title 10 of the Family Health Act to spell out exactly what Congress intended when it authorized federal funding for family planning. It would replace general language with a clear list of options that pregnant women must be presented with during counseling, including “termination of pregnancy,” according to Chafee spokesman Edward J. Quinlan. The bill was voted favorably out of committee last week and could be voted on by the full Senate this week.

Funding for Local Family Planning Services

Two weeks ago, the U.S. Supreme Court upheld federal rules barring federally funded family planning clinics from counseling women on abortion. Seventy-nine clinics run by 23 family planning agencies in Los Angeles County receive federal money, in addition to state funds.

Here is a look at how some clinics could be affected if they forfeited the federal money in order to continue to inform pregnant women that abortion is a medical option for them.

Family Planning State Federal Total Agencies Funding Funding Funding Los Angeles Co. $3,681,162 $1,194,366 $4,875,528 Dept. of Health Services Cedar-Sinai Medical Ctr 49,364 36,559 85,923 UCLA Med Center 92,688 87,492 180,180 Alta-Med Health Ctr. 84,001 59,521 143,522 American Indian Free Clinic 39,717 21,794 61,511 Chinatown Serv Center 54,321 30,439 84,760 East Valley Community Center 115,577 76,524 192,101 Harbor Free Clinic 109,762 37,869 147,631 Hollywood-Sunset Comm. Clinic 85,403 40,582 125,985 Koryo Health Foundation 60,245 44,052 104,297 Long Beach Family Planning 154,361 108,005 262,366 Los Angeles Free Clinic 112,000 27,473 139,473 Northeast Community Center 65,604 28,746 94,360 T.H.E. Clinic For Woman 107,305 79,971 187,276 Valley Free Clinic 78,982 42,942 121,924 Wilmington Community Clinic 91,401 38,780 130,181 Women’s Clinic 295,744 175,527 471,271 Westside Women’s Health Ctr 116,474 66,156 182,630 Family Planning Centers 122,972 115,856 238,828 of Greater Los Angeles Northeast Valley Health Corp. 159,771 36,153 195,924 Pasadena Planned Parenthood 284,846 98,922 383,768 Planned Parenthood/ 1,283,508 294,697 1,578,205 World Population/LA South Bay Free Clinic 255,072 138,871 393,943 TOTAL $7,500,280 $2,881,307 $10,381,587

Family Planning Federal Agencies Percentage Los Angeles Co. 24.5% Dept. of Health Services Cedar-Sinai Medical Ctr 42.5 UCLA Med Center 48.5 Alta-Med Health Ctr. 41.5 American Indian Free Clinic 35.4 Chinatown Serv Center 35.9 East Valley Community Center 39.8 Harbor Free Clinic 25.7 Hollywood-Sunset Comm. Clinic 32.2 Koryo Health Foundation 42.2 Long Beach Family Planning 41.1 Los Angeles Free Clinic 19.7 Northeast Community Center 30.5 T.H.E. Clinic For Woman 42.7 Valley Free Clinic 35.2 Wilmington Community Clinic 29.8 Women’s Clinic 37.2 Westside Women’s Health Ctr 36.2 Family Planning Centers 48.5 of Greater Los Angeles Northeast Valley Health Corp. 18.4 Pasadena Planned Parenthood 25.8 Planned Parenthood/ 18.7 World Population/LA South Bay Free Clinic 35.2 TOTAL 27.7%

SOURCE: Los Angeles Regional Family Planning Council