Nakara Alston was leaving her boyfriend when she learned she was eight weeks pregnant. In desperation, she got an abortion at a Planned Parenthood clinic in Albany, N.Y., and moved with her two daughters into a homeless shelter.
But something was clearly wrong. Several weeks after the procedure, she was still bleeding heavily and suffering from painful cramps. She took another home pregnancy test, and when it came back positive, the clinic staff assured her that they had seen the aborted fetus and there was nothing to worry about. It was only after she went to an emergency room that she discovered the problem: The baby was still in her womb.
Twelve weeks after the failed abortion, Ms. Alston went into labor and delivered a baby who quickly died.
Ms. Alston filed a malpractice suit against Upper Hudson Planned Parenthood, one of several complaints about patient care at the New York clinic that women have brought to her lawyer, Louis B. Oliver. “Planned Parenthood provides a very important area of medical care,” Mr. Oliver said. “But I speak out and have sued them because even disadvantaged people deserve good care.”
Planned Parenthood is synonymous with the fight to preserve abortion rights. But it is also the health care provider of last resort to millions of the poorest Americans. Its clinics offer cancer screenings, birth control, annual gynecological exams and prenatal care, regardless of whether patients can afford to pay. The organization is unique in its reach, one of the few health care providers with a presence in all 50 states.
But a New York Times review of clinic documents and legal filings, as well as interviews with more than 50 current and former Planned Parenthood executives, consultants and medical staff members, found that some clinics are so short of cash that care has suffered. Many operate with aging equipment and poorly trained staff, as turnover has increased because of rock-bottom salaries. Patient counts have shrunk from a high of five million and 900 clinics in the 1990s to 2.1 million patients and 600 clinics today.
The lack of resources is startling: Since the U.S. Supreme Court overturned Roe v. Wade in 2022, Planned Parenthood has enjoyed a fund-raising boom, with $498 million in donations that year. But little of it goes to the state affiliates to provide health care at clinics. Instead, under the national bylaws, the majority of the money is spent on the legal and political fight to maintain abortion rights.
Clinics are primarily funded by Medicaid payments for non-abortion procedures and donors who give directly to the affiliates. But there have been sharp reductions in government reimbursements. Arkansas, Missouri and Texas have blocked Planned Parenthood clinics from receiving Medicaid payments, an essential source of revenue, and a pending Supreme Court case could allow other states to follow suit. As he did during his first term, President Trump could deny abortion providers Title X federal family planning funds — costing Planned Parenthood clinics about $60 million.
At the same time, the Affordable Care Act, the signature domestic legislative accomplishment of former President Barack Obama, expanded health insurance options for low-income women and drove many poor women away from Planned Parenthood clinics to other health care providers. The coronavirus pandemic further shrank patient counts.
The case of the botched abortion in New York is one of scores of allegations reviewed by The Times that accuse Planned Parenthood of poor care.
In a case settled in California last year, a woman accused the organization of improperly implanting a birth control device in her arm and causing nerve damage.
A Nebraska clinician in 2022 did not realize that a woman was four months pregnant when she inserted an IUD. Several hours later, the patient was rushed to an emergency room and gave birth to a stillborn fetus.
For months last year at the North Central States affiliate, which oversees the Nebraska clinic, an understaffed nursing department did not upload sexually transmitted infection test results into charts, and patients wrongly believed that their results were negative when they did not hear back.
Many clinics are in dire need of upgrades and repairs. In Omaha last year, sewage from a backed-up toilet seeped into the abortion recovery room for two days, according to interviews with staff members and photographs and text messages shared with The Times. Employees shoved exam table pads under the bathroom door to block the leak. Patients vomited from the stench.
Employees at various affiliates said it was common to run out of over-the-counter pain medication and I.V. flushes. Salaries are so low that it is not unusual for staff members to qualify for Medicaid and federal food assistance.
Turnover is hovering at around 50 percent a year in many parts of the country, and clinic workers complained that they were learning from inexperienced peers. More than a dozen said they did not receive adequate training for patient intake, blood draws and other tasks.
“We’re begging for supplies, and we get denied constantly because they just can’t afford it,” said Ashley Schmidt, a training and development specialist in Nebraska who resigned in December.
Planned Parenthood executives declined to discuss individual patient complaints, citing privacy concerns and ongoing lawsuits. Patients who have sued over problems with their care also refused to speak publicly for fear of jeopardizing their cases. Planned Parenthood routinely requires patients who receive settlements to sign nondisclosure agreements.
In the case filed by Ms. Alston over her abortion in New York, which is still pending, Planned Parenthood officials also said privacy protections prevented them from commenting on the case.
But several former employees who have quit or were fired spoke openly about conditions in the clinics, and national leaders said that the organization is contending with tremendous challenges and still providing quality care in the vast majority of cases.
“Planned Parenthood works relentlessly to fill gaps in a broken health care system,” Alexis McGill Johnson, the president and chief executive of Planned Parenthood Federation of America, said in a statement.
“Every day, Planned Parenthood health center staff go to work and navigate obstacles few providers have to face: personal threats, intimidation, misinformation and politically motivated barriers,” she said. “They do so because they believe in reproductive freedom. The critical care they provide is deeply undervalued and inequitably reimbursed across the country.”
There are bright spots, especially in areas of the country that support abortion rights. Planned Parenthood in Illinois recently opened an 11,200 square foot, state-of-the-art facility in Carbondale, a few hours drive from the borders of Indiana, Kentucky, Tennessee, Arkansas and Missouri, which have banned or severely restricted abortion. The affiliate boosted salaries for staff and improved benefit packages as it prepared to welcome women from nearby states who were seeking abortions.
An affiliate in Ohio made substantial upgrades to an abortion clinic, and clinics in Southern New England have kept wait times low.
“We have an extraordinarily dedicated staff who deeply understand how hard it is for our patients to get the care they need and how important it is that our patients are able to get seen when they need to be seen,” said Amanda Skinner, the Southern New England affiliate’s chief executive.
‘Where are they going to give?’
There are 49 state affiliates of Planned Parenthood, and each is its own fief, with separate management structures and budgets — and different local political climates. Local fund-raising is robust in places like New York City and Los Angeles. Clinics in Nebraska and Kansas have had a harder time raising money locally, as anti-abortion sentiment in those areas grew.
Yet as the entire health care industry grapples with rising costs and the lingering damage of the pandemic, even clinics in states that support Planned Parenthood are feeling the squeeze.
Last year, Planned Parenthood of Greater New York — one of the few places where abortion is still legal up to 24 weeks — said that a budget shortfall would force it to restrict later term abortion services, effectively implementing a 20-week abortion ban. It closed four clinics.
Planned Parenthood of Northern New England expects to run an $8 million deficit over the next three years.
Planned Parenthood of Northern California made a hard funding choice last March when it ended a prenatal care program that served 200 to 250 low-income women a month.
Gilda Gonzales, the chief executive of Planned Parenthood Northern California, said that Contra Costa County had given her affiliate a $1.3 million contract to operate the prenatal program, but it left her to cover $379,000 a year in operating costs.
“Discontinuing the prenatal program was a difficult but necessary decision,” she said.
Over the last five years, the national office has distributed more than $899 million to affiliates, but none of it went directly to patient health care. By charter, the mission of Planned Parenthood Federation of America is to “provide leadership, advocacy and education in the field of reproductive health care.”
Much of the national funding to affiliates went to legal support, public campaigns to expand abortion access and subsidies for patient navigators who help patients access abortions. Some of it indirectly helped with patient services, including funding that subsidized telehealth services and upgrades for electronic health records systems, phone systems and online scheduling tools.
Ms. McGill Johnson, who leads the national organization, has pledged to share more funds with the affiliates. In an internal document obtained by The Times, her office said in May 2023 that it would make “strategic choices to invest our resources differently,” including more investments in technology and facilities.
But leaders say they have repeatedly prioritized the fight for abortion rights over clinics because the political fight was fundamental to the organization’s ability to operate.
In 1993, Planned Parenthood national leaders dropped health care expansion plans when an anti-abortion activist murdered a doctor in Florida, forcing the organization to lobby for clinic protections. Discussions over changing the funding structure fell by the wayside after Tea Party candidates swept into Congress in 2010 and began efforts to defund the clinics. In addition to the Medicaid cutbacks, more than a dozen states have cut abortion providers from their family planning funds.
Planned Parenthood leaders say that complaints about conditions in the clinics do not reflect the organization’s overall record of delivering quality health care.
“There are always anecdotal things that you can get from disgruntled staff people, a botched IUD,” said Joe Solmonese, chair of Planned Parenthood Action Fund, the political advocacy arm that spent $40 million to get pro-abortion-rights candidates into office last year. “But if you were to go to any clinic and ask how many IUDs they do, against anyone else who is doing them with this patient group, which has so many other health challenges, you will see that the health care outcomes are fine.”
Yet clinic employees said repeatedly in interviews that patients routinely encountered long waits, undertrained staff members and trouble even booking an appointment.
“I saw clients get turned away for services because they couldn’t afford it and the process of getting aid through Planned Parenthood took too long,” said Damien Hamblin, a medical assistant who worked at health care clinics before joining Planned Parenthood Arizona in 2022; he later left. “We’re supposed to be the organization for people that don’t have resources.”
‘A conveyor belt’
Employees said there has been constant pressure to more than double the number of patients seen from the present 2.1 million, to help bring in more revenues.
Planned Parenthood of Greater New York expects clinics to see more than four patients an hour, and for appointments to last about 10 minutes, according to an email sent by management to clinic staff obtained by The Times. The appointment times, set by Planned Parenthood Federation of America, are in line with a trend in health care, widely unpopular with both patients and doctors, to keep primary care visits to about 15 minutes.
But clinic staff members said that they need more than 10 to 15 minutes to provide compassionate care. Many patients have literacy and language barriers, or wrestle with social ills like housing insecurity, abuse and poverty. In New York City, employees said, patients often spend up to three hours in the waiting room for a non-abortion visit.
A former clinic manager in Columbus, Ohio, said that patients complained that they felt like they were in a factory.
Grace Larson, a former Planned Parenthood nurse in Minnesota who was fired while trying to unionize the staff, said that clinics were operating like “a conveyor belt” for patients. She said that employees sometimes administered expired pain medication or the wrong medications as they scrambled to move people in and out. She said it was not uncommon for patients to be taken to the wrong room and prepped for the wrong procedure.
“We would catch it when a patient would say, ‘Why am I in a room with an ultrasound machine and a sedation nurse for a Pap smear?’ or when a nurse would come in and be like, ‘Wrong room, wrong patient,’” Ms. Larson said.
Training has been a constant issue, especially for medical assistants, who are not required to have medical training to work in the clinics. They check in patients, prepare exam rooms, update patient accounts and collect payments.
But in many clinics, they also draw blood and take vital signs. Medical assistants in Ohio, Minnesota, Arizona, California, New York, Texas, Indiana and Illinois said they practiced blood draws and I.V. placements for an hour or so on a fake arm and then on a colleague before performing the procedures in clinics. But they said they sometimes ran into problems, and some said they did not know what to do when they arose. Mr. Hamblin, the medical assistant in Arizona, said that he was often asked to draw blood after other assistants had failed.
Clinic managers in many of the affiliates where employees have complained about conditions, including those in the Upper Hudson, North Central States and Greater Texas, declined to discuss specifics, but all of them reiterated their commitment to patient safety. They said their staff members adhere to the highest medical standards, receive comprehensive training and work with management to address concerns in a timely fashion.
‘One by one, there was no staff’
Clinic jobs can be emotional roller coasters, with constant attacks from anti-abortion activists and the pressures of serving a fragile client base with few resources.
Affiliate chief executives wear bulletproof vests to and from work. This past year, a clinic in Florida was firebombed; another in Helena, Mont., was shot at.
At the same time, many clinic employees said they felt a sense of mission going to work every day.
They recount stories of seeing children as young as 12 and 13 years old receive abortions, sometimes because a family member impregnated them.
“They would say, ‘Can you just hold my hand?’” said Deanna Evans, a former clinic manager in Tempe, Ariz. “I needed to be that person for these patients.”
Last year, a nationwide patient survey drew an overwhelmingly positive response, with most describing their visits as good or very good, though the survey represented only about 6 percent of the patients seen.
As for the staff, morale problems have persisted. In Arizona, a planning report in 2023 found that the affiliate was suffering from “prior operational mismanagement, a fragile financial state, and staff recruitment retention and morale issues.” The report cited “chronic underinvestment and negligence” among problems that had led to a “poor patient experience.”
In one incident, a young woman who received an IUD was told “it would be rough, and just ride it out,” according to a written complaint emailed to the office of the Planned Parenthood affiliate’s president. She said she suffered months of sharp pain and bleeding, but the phone system routed her mother’s calls for help to automated phone tree messages, according to the complaint. A new doctor found that Planned Parenthood had botched the procedure. The affiliate continued to bill the family, even though they had paid their balance, according to the complaint, which cited conversations with one of the affiliate’s billing employees.
Planned Parenthood Arizona declined to comment on the incident, citing privacy laws.
Several clinic employees there quit, citing a work culture they called “chaotic” and “toxic” and low wages, according to a separate 2023 report by an outside consulting firm. The report said that clinic staff members made about 20 percent less than other health care workers in the region.
“Staff have been explicitly told to get part-time work in order to cover their basic needs,” the report said. It said that staff members worked after hours without clocking in “because the work must get done.”
Ms. Evans, the former clinic manager in Tempe, was fired after hitting a man who refused to leave the premises. The day she was fired, morale bottomed. Her colleagues argued that the incident would not have happened had a clinic security guard been present.
Tempe employees quit or left for other Planned Parenthood health care centers. “One by one, there was no staff,” Ms. Evans said. The clinic — one of only two locations in Arizona that performed abortions — closed for eight months.
Erika Mach, the affiliate’s chief external affairs officer, said the clinics faced “the same challenges that plague the health care industry, which includes retention of health center staff.”
She said that the pay analysis study in 2023 resulted in a new compensation structure and a higher minimum wage, and that staff turnover was now the lowest it has been in three years.
Wealthy donors step in
Some of the nation’s richest donors have reached out to help Planned Parenthood. In 2022, MacKenzie Scott, the billionaire philanthropist, donated $275 million to be divided among Planned Parenthood’s national office and 21 affiliates.
The Illinois affiliate spent some of the $17 million it received on salary increases and better health care benefits. Others like Planned Parenthood of Southwest and Central Florida said that it placed the money in investment accounts to cover future deficits.
Officials have long debated whether wealthier affiliates should share more of their cash with peers and whether the national office should give unconditional funding to affiliates.
Cecile Richards, who died of brain cancer last month, made Planned Parenthood a political powerhouse when she led the national office from 2006 to 2018. She also recognized that the organization’s structure created financial and leadership issues that were becoming harder to ignore. She wanted to winnow the affiliates to a few regional entities to eliminate duplicate administration costs and reduce the number of executives, who are often highly compensated, according to four former Planned Parenthood executives.
Some consolidation occurred when weak affiliates merged with stronger peers.
Executives said that the mergers often saved clinics, but some had mixed results.
Planned Parenthood of New York City was one of the strongest affiliates. It had wealthy donors, celebrity-filled fund-raisers and a State Legislature that supported abortion rights and paid some of the highest state Medicaid reimbursement rates in the country. But clinics in the rest of the state had fewer donors.
In 2019, New York City agreed to become part of a new entity called Planned Parenthood of Greater New York, which included affiliates in Nassau County, the mid-Hudson Valley, Southern Finger Lakes and Mohawk Hudson.
But some of the chief executives of the five affiliates, who made a combined $1.5 million a year before the merger, balked at taking pay cuts. Two of them left not long after the transaction closed in January 2020.
Then the coronavirus outbreak stopped the flow of patients, wiped out revenue and threw the enormous new affiliate into tumult.
Greater New York has since laid off and furloughed hundreds of employees. This fall it announced it would cut medical assistants and supervisors, close locations and impose the 20-week abortion limit.
A ‘mission moment’
Scores of former employees have sued Planned Parenthood, raising complaints that include refusing to pay overtime or provide breaks, pushing out employees who needed time off to deal with injuries or newborn babies, and firing people who complained about discrimination or clinic practices.
Planned Parenthood said that it does not retaliate against employees. The organization has settled most of these claims.
Dozens of current and former employees also said that their complaints were met with reminders that they were in a “mission moment,” meaning a time of crisis for reproductive rights so urgent that it overshadowed their concerns.
Some have worried that criticizing practices in the clinics could empower the anti-abortion movement at a time when the organization faces more challenges than ever before.
So many remain quiet. “We’re afraid of damaging the mission,” Mr. Hamblin said.
The post Botched Care and Tired Staff: Planned Parenthood in Crisis appeared first on New York Times.
