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How state governments are running

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Photographs by Agnes Thor

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abortion providers out of business

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By Esm E. Deprez

In January 2011, Michigan State Senator Rick Jones, a former sheri from Grand Ledge, introduced legislation that would dramatically raise the costs of providing abortions in the state. Senate Bill No. 54 would require fetal remains to be cremated or buried separately from other medical waste and make noncompliance a felony punishable by up to three years imprisonment or a ne of up to $5,000, or both. Soon after the bill was introduced, Rene Chelian, a petite 61-year-old who opened her rst abortion clinic in suburban Detroit in 1976, called every funeral director and cremation company in the metropolitan area to see if theyd be willing to handle fetal remains from her clinics. Most told her no. When she nally found one willing to comply with the guidelines, the quoted price was $250 per disposalwhich would nearly double the cost of most abortions at her clinics and was way more than most patients could a ord. If the Jones bill as initially proposed were to become law, Chelian calculated, she and other abortion providers might go out of business. Intimidation, harassment, and the threat of violence used to be Chelians biggest preoccupations. Her photo is posted on antiabortion websites, her home has been regularly picketed, and one of her clinics was once doused in butyric acid, a clear, colorless liquid that smells like 1,000 people lined up and threw up, she says. In recent years, however, the main threats to abortion providers have come not from noisy picketers and protests but from regulations passed in statehouses across the U.S. Requirements that abortion providers be regulated more like hospitals than doctors o ces may shutter most, if not all, clinics in Virginia, Kansas, and Pennsylvania. A Mississippi law mandates that abortion doctors secure admitting privileges at local hospitals, and could force the states last surviving clinic to close its doors. Instead of seeking to ban abortion outright, which would violate the Supreme Courts 1973 ruling in Roe v. Wade, anti-abortion groups are pushing laws that would make it too expensive for providers to remain in operation. If someone woke me up at 2 a.m. and asked me whats the greatest threat to providers today, these laws would be the first thing Id say, says Carole Jo e, a reproductive health sociologist at the University of California at San Francisco whos chronicled the abortion industry for the past 35 years. The headquarters of Northland Family Planning are located in the Detroit suburb of Westland, in a standalone one-story building separated by parking lots from a GameStop and a bank. On a cold morning in early January, Chelian is trying to decipher how newly passed regulations will a ect her business. She takes a call on her iPhone from a representative from a medical waste company that Chelian worries will face pressure from anti-abortion activists to drop her as a client.

A new Michigan law requires recovery rooms in abortion clinics to have 80 square feet of oor space per bed

Chelians clinics billed $3.5 million last year, yet she still took a small loss

To comply with regulations, Chelian may need to build a new janitors closet

I dont want them to start harassing you, she says. Do you have any vehicle you can pick up in that doesnt have your name? Yes, the man replies. I mean, its your business and you have to do what you have to do, but I dont want to lose you as a contractor because you had the name on your truck. She hangs up. Without medical waste pickup, were in trouble, she says. Its one of the rst times in months that Chelian has been in her office. Unpacked boxes from a 2010 renovation surround her desk. For the past two years, Chelian delegated payroll and other clinic-running duties to employees while she logged some 11,544 miles in her dark gray Ford Explorer driving to and from Michigans capital, Lansing, to lobby lawmakers and participate in rallies against a host of anti-abortion proposals. Chelian grew up in inner-city Detroit, the oldest of ve children born to a SyrianLebanese Muslim father and an Irish Catholic mother. In 1966, at the age of 15, she had an illegal abortion. Her father accompanied her to a parking lot where they were blind-

folded and taken to a nearby warehouse. For $2,500, a man packed her uterus with gauze to induce labor, and after some complications, she passed the pregnancy on the toilet at home. She now guesses she was about 16 weeks along. It was decades before she told anyone about the experience, which provided motivation for her career. I dont want my daughters or any other woman to be faced with that, she says. In 1976, having taken some nursing classes, Chelian was working as an assistant to an abortion doctor and felt she could run things better. She envisioned a model that o ered emotional counseling to women undergoing abortions. She and her husband, Eddie, a policeman at the time, opened Northland using their life savings of $100,000. Shes since expanded the business to three clinics in the Detroit area. In 2011, Northlands ve doctors performed nearly a quarter of the 23,366 reported abortions in the state. In virtually any other context, a taxpaying small business owner like Chelian, who employs 36 people and has invested millions

of dollars into her 37-year-old enterprise, would be praised by politicians as the backbone of the American economy. In places where abortion is accessible, its partly because people like Chelian recognize it as a business opportunity. Chelians clinics had gross revenue of $3,520,576 for scal 2012 but lost $1,818, according to their accountant. Even so, Chelian and her husband, who oversees security and nances at the clinics, earned $203,000 last year in salary. They live in a 6,500-square-foot home in the upscale neighborhood of West Bloom eld, near where Mitt Romney grew up. My husband and I worked our ass o to make sure we paid for our kids college education, she says. And yet Chelian has dealt with challenges that few others in the healthcare eld must face. She spends thousands of dollars annually on security guards and has hired private detectives to monitor opposition groups plans. She has had two lease renewals denied and was evicted once because of protests staged outside her clinics. Wary of her image when she testi es in Lansing, she removes the 2-karat diamond engagement ring her husband gave her more than 40 years ago, lest she fuel a perception of herself as a pro teering abortionist. On Dec. 28 last year, Michigan Republican Governor Rick Snyder signed an omnibus bill combining multiple abortion-related measures. It was the culmination of two years debate about whether and how abortion should be regulated in the state. The nal law prohibits doctors from prescribing medication abortion, a chemically induced miscarriage, via webcama practice used in some states to expand access to rural communities where doctors arent physically present. The law also requires that patients be screened to ensure they werent coerced into getting an abortion. Providers who advertise outpatient abortion services and perform 120 or more surgical abortions per year must now be licensed as freestanding surgical outpatient facilities. Anti-abortion groups lauded the bills passage. Licensing and inspecting abortion clinics for health and safety standards will serve to better protect those women who, regrettably, choose the path of abortion, said Rebecca Mastee, a policy advocate at Michigans Catholic Conference. At the same time, the legislation signed by Snyder represented a victory of sorts for abortion rights advocates. They succeeded in throwing out or diluting provisions such as a ban on abortions beyond 20 weeks and a requirement that abortion doctors have personal liability coverage of at least $1 million. The fetal remains disposal measure introduced in the state Senate was modi ed to allow the incineration of fetal tissue along with other medical waste, and reduced the penalty for noncompliance to a civil ne of $1,000. The most threatening part of the new legislation is the need to conform to hospital-

like standards, says Chelian. One stipulation requires abortion clinics to install special gooseneck scrub sinks. Another says recovery rooms must provide 80 square feet of oor space per bed, three feet between each, and one lavatory for every six patients. Corridors must have a minimum width of six feet Chelian estimates most are currently closer to ve, which is large enough to t a stretcher. Unless she can successfully attain waivers for such things, Chelian estimates the needed renovations would cost more than $1 million, an expense she says she cant a ord. Chelians clinics perform 19 abortions per day on average. If patients are required to remain in recovery for at least three hours, with a physician present the entire time, that number would be cut in half, which could force Chelian to raise her rates. Many clientsoften minorities, poor, and uneducatedalready have difficulty scraping together the $325 that most abortions (up to 12 weeks gestation) cost. That price subsidizes the costs of pap smears, contraception such as birth control pills and condoms, and other services that make up the majority of her business, she says. Denise Burke, the lead author of regulations at Americans United for Life, which helps to write legislation like Michigans, argues that the courts have never stipulated that abortions must be a ordable or that providers ought to earn a pro t. To underscore the point, she cites the high courts own words in the landmark Planned Parenthood v. Casey in 1992, which upheld states rights to restrict access: The fact that a law which serves a valid purpose, one not designed to strike at the right itself, has the incidental e ect of making it more di cult or more expensive to procure an abortion cannot be enough to invalidate it. Charmaine Yoest, the president of Americans United for Life, points to the 12 women who died from abor-

tion in 2009 and examples of lthy clinics discovered in Kansas and Pennsylvania as proof that all abortion care must be more closely regulated. That argument is echoed by Jones, the sponsor of Michigans fetal remains bill. What we have done is make a safer environment for all women in Michigan, he says. Federal data show abortion to be one of the safest medical procedures in the U.S., posing less risk of death than getting a penicillin shot and 14 times safer than carrying a pregnancy to delivery. Anyone who talks about the dangers of abortion is just blowing smoke, says David Grimes, former chief of abortion surveillance at the Centers for Disease Control and Prevention and a leading researcher and abortion provider. These kinds of regulations do nothing to advance womens health. All they do is drive up the cost of care and cause women to delay, which drives up the risks. Under the Obama administration, abortion rights proponents have won signi cant battles on the national level, ghting back attempts to cut o funding to Planned Parenthood and eliminate the A ordable Care Acts requirement that most health plans cover contraception free of charge. But abortion foes have made unprecedented headway at the state level. After Republican gains in statehouses in the 2010 midterm elections, lawmakers in 24 states passed a record 92 provisions that restrict access to abortion services, according to the Guttmacher Institute, which researches and compiles data on reproductive health. Thats nearly triple the old record set in 2005 and a sixfold increase over 1985. Abortion providers say the laws have made their business more arduous and sliced into their earnings. By 2008, the latest year for which Guttmacher has data, the number of providers, which includes doctors o ces and hospitals, had fallen 38 percent from their 1982 peak, to 1,793. Independent, forprofit clinics like Chelians are where the majority of abortions in the U.S. are performed. But they lack the lobbying muscle, fundraising capabilities, and public funding of Planned Parenthood, the countrys single largest abortion provider, and are thus more vulnerable to regulation. Many of the 26 indies that have closed in recent years say its because theyve been run out of business by or forced to merge with Planned Parenthood a liates, and 19 more say theyre in serious trouble, according to an informal survey conducted by independent providers. Demand is also declining: The abortion rate fell in 2008 to its lowest level since 1974, according to Guttmacher, due in part to more e ective contraceptives. That financial squeeze on providers is likely to continue. Legislation pushed by abortion opponents increasingly targets the supply side of abortion (the providers) over the demand side (patients),

THESE KINDS OF REGULATIONS DO NOTHING TO ADVANCE WOMENS HEALTH. ALL THEY DO IS DRIVE UP THE COST OF CARE AND CAUSE WOMEN TO DELAY, WHICH DRIVES UP THE RISKS
David Grimes, former chief of abortion surveillance at the Centers for Disease Control and Prevention

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part of an aggressive new thrust on the part of abortion opponents, says Theodore Joyce, a research associate at the National Bureau of Economic Research and economics professor at By Jennifer Daniel Baruch College. and Allison McCann ND LA Its an e ective strate y. In his 2011 RY A M New England Journal of Medicine article, Utah, as well as South Dakota, The Supply-Side Economics of Aborexpanded the waiting period tion, Joyce used Texas as a case study to before an abortion from 24 to 72 H TA hours, the longest in the country compare demand- and supply-side laws. U The Womans Right to Know Act, which took e ect in 2004, contained components of both. On the demand side, it required patients to wait 24 hours before undergoing an abortion; on Arizona bans the supply side, it required abortion at 18 weeks providers performing abor- post-fertilization tions at or after 16 weeks ges- (20 weeks after the womans last period), tation to be ambulatory surgi- two weeks earlier cal centers, which none of the than all other states states non-hospital providers were at the time. Joyce found that the demand-side measure had no effect: From 2003 to 2004, women less than 16 weeks pregnant underwent abortions at the same rate. But the supply-side policy had all the bite, he says: Abortions in the state conducted after 16 weeks declined by 88 percent. Courts are now clogged with challenges to the new wave of regulations imposed on abortion providers. Even in cases where waivers and grandfather clauses exist, states have created an environment that makes it practically impossible for any new medical practices to open, says Nancy Northup, president of the Center for Reproductive Rights, which provides clinics like Chelians with pro bono legal assistance. Michigans law also prevents abortion providers from transferring licenses: If Chelian dies, Northlands doors close for good. For now, Chelian has a business to run. There are more than a dozen other clinics within an hours drive. She competes by offering the cleanest and most comfortable surroundings and best-trained staff, she Virginia passed laws says. Examination rooms have requiring women soft music piped in, overhead living within 100 miles lights are on a dimmer, and of a clinic to receive in-person counseling landscapes hang on the walls. Ever and an ultrasound 24 the entrepreneur, Chelian is look- hours in advance ing to expand: Northland began offering adoption services last year and is now eyeing in vitro fertilization. After being hesitant early on, she no longer shies away from marketing what NorthA Mississippi law mandates that abortion land is best known for. doctors secure admitting privileges at While we are a medical clinic that local hospitals and OB/GYN certication, provides a medical service, we are also a and could force the states last surviving clinic to close its doors business, she says. Were not trying to sell it to someone who doesnt want one, but for someone who wants an abortion, we want them to choose us. Why would I let the [anti-abortion] movement make Louisiana requires providers to make the fetal heartbeat audible me ashamed of that?
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Both Indiana and Kansas require counseling that the fetus is a person
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Kansas prohibits state agencies or employees from participating in abortions, e ectively preventing any public hospitals from performing abortions
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In the past two years, 30 states have passed 135 new restrictions on access to abortions
Each symbol indicates a law passed in the state:

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Clinic regulations Nebraska and Kansas require parental consent before a minor obtains an abortion
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-2012 on laws

North Dakota requires warnings about the increased risk of breast cancer due to an abortion, a claim proven false by the National Cancer Institute

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Oklahoma allows lawsuits against providers for any violation of state abortion regulations

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South Dakota enacted regulations that require counseling about dubious risk factors

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Along with Arizona, Kansas, Nebraska, North Dakota, Oklahoma, and Tennessee, South Dakota prohibits the use of telemedicine limited only to abortion medication

Florida signed into law a measure that bans abortion coverage in the health exchanges that will be established under the federal health-care reform law; Idaho, Indiana, Kansas, Nebraska, Ohio, Oklahoma, Utah, and Virginia passed similar measures

Arkansas requires providers that perform at least 10 abortions per month to meet certain abortion clinic requirements and be inspected by the Arkansas Department of Health

GRAPHIC BY BLOOMBERG BUSINESSWEEK; DATA: GUTTMACHER INSTITUTE

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