Angered by videos in which Planned Parenthood officials discussed compensation for providing fetal tissue from abortions, Republicans in Congress are again demanding an end to government funding for the nearly 100-year-old provider of women's health services.
Away from the headlines, however, the group is facing other major challenges, including one from a far different source: the Affordable Care Act, which it avidly supports.
Many formerly uninsured women who once depended on Planned Parenthood for low-cost access to birth control, abortions and other reproductive healthcare have gotten coverage under President Barack Obama's healthcare law, making them less reliant on the organization's 700 clinics.
In many states, Planned Parenthood is losing clients as newly insured patients turn to medical providers included in their health plan's networks, according to data provided to Reuters and interviews with more than two dozen of its affiliates.
"Some people relied on us because they were uninsured prior to the Affordable Care Act. Now they can go anywhere for care, and some of them have been," said Lori Carpentier, president and CEO of Planned Parenthood of Mid and South Michigan, which expects to treat 58,000 patients in 2015, down about 15 percent from the 68,000 it treated in fiscal 2012, before major parts of the law went into effect.
The ACA has also brought some benefits to the organization, its leaders say. In interviews, affiliates all reported a significantly larger percentage of insured visitors among their remaining patients. Some locations - including Ohio, New York City, Chicago and the Northwest - are even adding clients as they expand services to better compete for women with medical coverage.
Still, Planned Parenthood client numbers nationwide are on the decline. Part of the drop in patient numbers can be traced to decisions by legislatures in Republican-leaning states like Texas to cut funding to affiliates beginning in 2011.
The declines then accelerated after Obamacare took full effect in 2014, when Planned Parenthood served 2.68 million patients, down about six percent from 2.84 million a year earlier, according to numbers last updated in July.
The decline was apparent even in areas like upstate New York, New England and parts of the Midwest, which have not seen decreases in state funding.
Some declines are considered positive. The U.S. abortion rate is down, for example, and Obamacare has increased contraceptive coverage, making it easier for women to afford long-lasting birth control methods such as IUDs, which require fewer office visits.
"Data about health centers and patients will fluctuate," said Kim Custer, executive vice president of health care, Planned Parenthood Federation of America. "But at the end of the day, Planned Parenthood has a unique relationship with our patients, some of whom would not be able to get healthcare anywhere else."
The National Right to Life Educational Trust Fund, an arm of one of the nation's biggest anti-abortion groups, said the numbers could suggest that women are acting on their beliefs once they have a choice of provider.
Insurance coverage allows them to "go someplace where they can get a broader range of services and can avoid a place that also does abortions," said Randall K. O'Bannon, director of education and research at the group.
A DIFFERENT MODEL
Planned Parenthood's latest public battle has come from the anti-abortion group Center for Medical Progress, which began posting secretly recorded videos online in July. The center says the tapes show Planned Parenthood engaged in illegal sales of fetal tissue. Planned Parenthood denies the charges, saying that a few affiliates donate tissue for research and are paid a small fee to cover costs.
In recent weeks, citing the videos as a reason, several Republican-leaning states including Louisiana and Alabama have moved to defund Planned Parenthood by ending agreements under the Medicaid program for the poor. Democrats are calling the controversy a "War on Women," saying it could delay final action on the federal spending bill.
But even before the most recent dispute, Planned Parenthood had begun reconsidering its model of serving primarily the poor. It has spent hundreds of millions of dollars in recent years to expand services, upgrade buildings and improve customer service, hoping to better compete for more affluent insured patients and tap a more stable source of revenue than public funding.
Many states now provide services that promote broader wellness and preventive healthcare, including prenatal care, screenings for men, sex education for teenagers and smoking cessation counseling.
"The Affordable Care Act hit at the same time we were defunded by the state," said Kelly Hart, director of government relations at Planned Parenthood of Greater Texas. "We realized we needed to diversify our patient base if we wanted to be viable in the 21st century."
The law is reshaping U.S. healthcare, encouraging consolidation of hospitals and medical practices and increasing competition from walk-in clinics. About 17 million more people have insurance now than in 2013 through private insurance plans, many of which are subsidized by the government, or the expansion of Medicaid, according to the Rand Corp.
"Twenty-five years ago, this was about rights, justice and access," said Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association and a former Planned Parenthood affiliate CEO. Now there are additional concerns. "Can you make it financially? Do you have the right revenue mix? Are you running in debt or running a reserve?"
A major focus is to attract Millennials, now in their 20s and early 30s, with online scheduling and short wait times. Some affiliates are trying programs that use smartphone apps to help determine if patients need tests, access birth control and provide advice without an office visit.
Many are offering more services to men, older women and the gay and transgender communities. They also are expanding partnerships with other medical providers. One affiliate in the Midwest, for example, works with pediatricians who refer sexually-active teenagers interested in obtaining an IUD.
Last month, painters added finishing touches on a new $9 million, 14,000-square foot Planned Parenthood health center in Long Island City, Queens. Just beyond the guarded entrance is a round sign that says "Welcome" in 11 languages.
The atmosphere is bright and airy with walls painted in shades of yellow, blue and green, with no obvious references to reproductive health other than the name.
"You have to have a great customer experience," said Joan Malin, president and CEO of Planned Parenthood of New York City, which oversees the Queens facility. "Word of mouth brings people in."
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