I run an abortion clinic in Arizona, and every month the ledger asks the same unforgiving question: do we have enough cash to keep the promise alive? The financial challenges of abortion clinics are one of many factors that affect reproductive rights in America.
When the U.S. Supreme Court’s Dobbs decision came down on June 24, 2022, my heart felt the aftershock, but my brain also focused on my payroll. Nurses, front office staff, medical assistants: their paychecks are non-negotiable.
Meanwhile, operational costs like rent, supplies, and malpractice premiums keep increasing, and the independent-clinic map keeps shrinking.
Since Roe fell, several dozen clinics have already gone dark. Those closures echo through every line of the budget: longer waits, costlier supplies, exhausted staff. Every closure pushes more patients to fewer open doors, stretching supplies and staff. I’d like to share where the money goes and why every dollar we scrape together is an investment in the future of reproductive justice.
Making Payroll Is Sacred Work
The people who open our doors each morning do more than clock in. They stand in the line of stigma, protest, and politicization. That reality shapes how I budget for payroll.
Since opening in 2013, I have never paid minimum wage. Even back then, my nurses earned a competitive wage of $14 an hour. Staying competitive now means paying nearly triple the 2013 rate, because quality care requires quality staff.
Competitive pay is only the start. I decided early that every employee would have employer-subsidized health insurance. Premiums climb each year, and I absorb part of that increase because “being fair to staff” means sharing the cost, not passing it along in full. Maintaining coverage through pandemic shutdowns, political whiplash, and Dobbs turbulence has strained our margins, yet dropping benefits would betray the covenant we ask of this team.
Independent clinics across the country face the same pressure. At the Women’s Health Center of West Virginia, losing abortion revenue overnight threatened 40 percent of the clinic’s budget, placing staff stability on the line in a budget crisis after Dobbs. Their scramble to protect payroll echoes mine: every raise, every insurance renewal, every training stipend lands on a spreadsheet already warped by politics.
Payroll is the backbone of our mission infrastructure. It’s the foundation that supports every other line item.
Dilapan and Aging Equipment
Supplies once considered routine now arrive with punishing markups. My sharpest example is Dilapan, the osmotic dilator used for later abortion procedures. When I opened the clinic, a box of 25 cost roughly $500. The sole U.S. distributor now charges $2,000, a fourfold jump that landed when the company reminded us it has no competitor.
I must decide to the mark-up cost, find an alternative solution, or turn patients away. There aren’t many bulk-discount negotiations for abortion care.
Equipment presents a parallel crisis. Manufacturers have discontinued reliable suction units and accessories, replacing them with pricier models that, in my experience, work less effectively. Clinics nationwide, including mine, have been scouring eBay for used machines and spare parts because new gear is scarce and overpriced. Each online bid feels like a stopgap, but a broken motor could halt procedures for weeks without it.
The leverage vendors hold over abortion providers affects larger systems, too. In New York, Planned Parenthood temporarily suspended abortions past 20 weeks after anesthesia vendors raised their service fees beyond the affiliate’s budget, demonstrating how a single inflated quote can erase an entire gestational window of care.
None of these costs are detailed on a patient’s bill, yet they dictate what I must charge to keep the clinic solvent. When a single box of Dilapan swallows $2,000, or a used suction part ships across the country because the new one is unattainable, material overhead stops being background noise.
Equipment and supplies are a financial tightrope abortion providers must walk, with one overpriced component away from shutting down a procedure room.
Security, Lawyers, and the Politics of Compliance
After supplies, abortion providers like me face costs for security and compliance. Abortion opponents do not simply disagree with me. They legislate, litigate, and intimidate, costs that appear nowhere on the profit and loss statements of a dermatologist or other medical provider.
At Desert Star Institute for Family Planning, we maintain 24-hour camera coverage, shatter-resistant windows, and Phoenix Police Department detectives on speed dial. Security and equipment expenses have increased after the Dobbs ruling.
Then come the lawyers.
Each year brings a new stack of state inspections and rule rewrites: hallway widths, janitorial-closet dimensions, mandatory transfer agreements. I retain counsel to protect the clinic from unfounded legal attacks.
That reality is not unique to Arizona. A national survey of independents found that legal and regulatory fees now rank among the top barriers to staying open, eclipsing even rent in some markets—a pattern Bloomberg described as the “nickel-and-diming” of abortion care regulatory costs.
These hidden expenses drain resources that should fund patient care and staff well-being. When a surprise inspection forces the installation of a different air-handling unit, that invoice competes with trauma-therapy stipends for clinic counselors. When a new city ordinance mandates additional fencing, that cash comes straight out of the supply budget.
The math is ruthless: every politically motivated requirement shifts dollars away from actual healthcare. And as the rulebook thickens, the reimbursement landscape remains stuck.
This imbalance leads straight into the next financial wall: Medicaid.
Where Medicaid Pays Half the Bill
In some states, public insurance helps some patients, but the check that follows rarely covers the care they receive. Since 2008, my colleagues in Connecticut have been reimbursed at a stagnant rate as their costs have continued to climb. They’ve had to address the shortfall with private donations or cross-subsidy from other services.
Stop-gap support exists, but clinics can’t patch every hole. The Keep Our Clinics campaign distributed roughly $1.9 million to independent facilities in 2024. Even with those infusions, reimbursement gaps and rising costs leave many providers operating on a razor-thin margin.
Each under-reimbursed visit widens the crack in our financial foundation. As public payments stall, or are non-existent, like Arizona, where my clinic is, and emergency grants fluctuate, clinics that remain open shoulder growing patient loads, a burden compounded by the shrinking map of providers.
Fewer Clinics, Longer Journeys, and Higher Stakes
Since the Dobbs decision, the United States has lost 42 brick-and-mortar clinics between 2020 and 2024, a five-percent decline, leaving 14 states with none.
A separate review found an 11-percent drop in facilities offering procedural care, with more than 100 sites closing or switching to medication-only services. Each closure sends a ripple: appointment calendars stretch from days to weeks, second-trimester cases edge later, and travel miles pile up on patients juggling time off and child care.
The financial strain we shoulder as providers lands squarely on patients, too. However, they keep coming, proving demand does not disappear when lawmakers erase supply.
Staff feel the strain, too. This work requires resilient people, but resilience is no substitute for sustainable policy and funding.
Access is turning into a test of endurance, and endurance alone will not keep doors open.
Shoring up access will take more than individual grit. Three levers matter most:
- Policy that funds infrastructure. New Mexico set a precedent when the governor earmarked $10 million for a new clinic near the Texas border. The funds would cover bricks, mortar, and staff salaries instead of crisis-grant triage state investment in a border-zone clinic. Similar capital funds could stabilize service deserts across the South and Midwest.
- Reimbursement that reflects reality. The 51-percent Medicaid rate in Connecticut is symptomatic of low reimbursements that ripple everywhere. Legislatures can prioritize raising rates tomorrow. They can also restore Title X dollars stripped by federal gag rules, plugging predictable money into preventive care instead of go-fund-me cycles.
- Sustained community investment. Small-dollar gifts kept many independents alive through the first Dobbs winter, yet giving dropped by a third the following year. My clinic experienced this. No matter how modest, monthly commitments let clinics budget for staff health insurance and emergency repairs without gambling on the next court headline.
States already underwriting clinic construction prove that capital investment works. Medicaid agencies raise dialysis rates every year; they can do the same for abortion care. Donors who automate $10 a month become the reason why we can maintain our commitment to health insurance for staff, instead of scrapping it to reduce expenses.
I am ready to keep practicing medicine. But this ministry I’ve chosen needs electricity, security, and living-wage paychecks. Public health needs policies that treat abortion like the essential care it is.
When we can fully fund infrastructure and operational expenses, the conversation shifts from “Which clinic closed this week?” to “How far will this network reach?”
That’s a future worth backing.
