In Missouri, Battles Over Birth Control Foreshadow a Post-Roe World

ROLLA, Mo. — For more than half a century, Tri-Rivers Family Planning has operated on a shoestring budget, providing contraceptives, pregnancy testing, treatment for sexually transmitted diseases and other reproductive health care to a mostly low-income and female clientele here in the Ozark Mountains.

The clinic has never performed abortions. But with the Supreme Court widely expected to revoke the constitutional right to abortion that it established in Roe v. Wade, its work has never been more essential — and its nurse practitioners and patients have never felt more threatened.

Last year, the Republican-led Missouri Senate voted to ban taxpayer funding for two common methods of preventing pregnancy: intrauterine devices and emergency contraception — the so-called morning-after pill, also known as Plan B — which many abortion opponents regard as “abortifacients” because they can prevent a fertilized egg from implanting in a woman’s uterus. Lawmakers later abandoned the effort, but some have indicated that if Roe falls, they may try again.

“The attacks are relentless — any little angle they can chip away at what we do, they are doing it,” said Lisa Ecsi Davis, the clinic’s director of operations, who has worked at Tri-Rivers for 30 years. “It’s exhausting.”

The demise of Roe would make the need for effective birth control more urgent than ever. Yet nearly six decades after the Supreme Court guaranteed the right to use contraception, and more than 10 years after the Affordable Care Act mandated that private insurers cover it, many American women still have a hard time getting access.

Funding for Title X, the federal safety net program that helps finance family planning clinics like Tri-Rivers, has been flat for more than a decade. Private insurers do not always cover the full cost of contraception, despite the A.C.A. requirement. Six states allow pharmacists to refuse to fill birth control prescriptions for religious or moral reasons, without taking steps to help patients get them filled elsewhere.

“This is our daily life,” lamented Rachel Goss, the executive director of the Family Planning Council of Iowa, which administers Title X grants in that state. “You’re fighting this constant uphill battle just to provide safe — and right now, legal — care.”

Congressional Democrats, sensing a potent political issue in the upcoming midterm elections, are pushing to expand access to birth control.

Last week, they introduced legislation to require insurers to fully cover any F.D.A.-approved birth control pills, including emergency contraception, which costs as much as $50 over the counter — far too much for those struggling financially.

But some Republicans on the far right have sought to broadly limit access to emergency contraception, which prevents pregnancy when taken within several days of unprotected sex.

“The idea that we might now be facing fights on contraception is something that is very hard to wrap your head around,” said Elizabeth Nash, an expert in state policy at the Guttmacher Institute, a research group that supports abortion rights. If abortion opponents persuade lawmakers to define pregnancy as starting at fertilization, she said, it “could cause complications in being able to provide contraceptive care.”

Texas already bars its state family planning programs from paying for emergency contraception. Missouri, one of 13 states with “trigger laws” that would immediately ban abortion if Roe is overturned, is becoming another front in the battle over birth control — and may foreshadow what is to come in a post-Roe world.

In February, it became the fourth state — after Arkansas, Mississippi and Texas — to eject Planned Parenthood, a major provider of birth control nationally, from its Medicaid program. Planned Parenthood has asked the Biden administration to intervene, saying the move violated federal law. A spokeswoman for the federal Centers for Medicare and Medicaid Services said the agency was “considering the policy options within its authority.”

In the meantime, Medicaid patients must find care elsewhere — and often endure long waits for appointments, said Michelle Trupiano, the executive director of the Missouri Family Health Council, the nonprofit that administers Title X grants in the state.

Here in Rolla, a small city of about 20,000 people that sits along historic Route 66, Hailey Kramer, the chief nurse practitioner at Tri-Rivers, said her patients make clear that birth control is a deeply personal decision.

Kaitlyn Ball, 24, became pregnant while taking birth control pills and now has a 3-year-old; she does not want to get pregnant again. After consulting with Ms. Kramer, she got an I.U.D.

Taylor Gresham, a 25-year-old dancer, has been a patient at Tri-Rivers since the summer before her senior year in high school, when she discovered she was pregnant. After she got an abortion, the clinic provided her with Depo-Provera. Her mother thought it was a good idea, she said, because “a high school kid is probably not going to take a pill every day.”

After she graduated, Ms. Gresham opted for an I.U.D.; more recently, she started taking birth control pills again. “I’m on a better routine with my life,” she explained.

In 1965, in a case that provided the legal blueprint for Roe, the Supreme Court declared that married couples had a constitutional right to use contraception. Its decision in the case, Griswold v. Connecticut, established a right to privacy that the court said was implied, if not delineated, in the “penumbras” of the Constitution — the same rationale it invoked eight years later in Roe.

Griswold put contraception at the forefront of the national conversation at a time when policymakers were focused on ending poverty; in 1969, President Richard M. Nixon declared that “no American woman should be denied access to family planning assistance because of her economic condition.” Title X was established by Congress the next year to help pay for the care that so-called family planning clinics provide to low-income patients, who are charged fees based on family size and income.

Old newspaper clippings show that Rolla’s mayor came to the ribbon-cutting when Tri-Rivers — initially an affiliate of Planned Parenthood — was founded in 1971, and more than 100 Rolla merchants made donations to get the clinic going.

Last year, Tri-Rivers cared for more than 1,800 patients, more than half of whom were uninsured. The clinic gets $250,000 a year, just under half its total budget, in Title X dollars — an amount that has “stayed the same for many years,” said Toni Stubblefield, its president and chief executive.

The clinic, which serves roughly a 10-county area and sits halfway between St. Louis and Springfield, once had two satellites. One closed years ago, the other last year, a victim of tight budgets and Covid-19.

Some Tri-Rivers patients must now drive three hours round-trip to be seen — a challenge that keeps some women, especially those who work or have young children, from being seen at all.

Power to Decide, a reproductive rights advocacy group, estimates that more than 19 million American women live in “contraceptive deserts,” which it defines as “counties in which there is not reasonable access to a health center offering the full range of contraceptive methods.”

The years when Donald J. Trump was president brought some of the biggest struggles yet for family-planning clinics. The Trump administration’s “gag rule” barred Title X grant recipients from referring patients for abortions. Ms. Ecsi Davis posted signs about the rule on the Tri-Rivers’s walls, a not-so-veiled critique.

“It just always felt wrong, to not be able to give people the information that they were asking for,” said Ms. Kramer, the nurse practitioner.

Then came 2021, and the Missouri Senate’s vote to bar Medicaid funding for Plan B and I.U.D.s.

“I’m a devout Catholic and believe that life is sacred from the moment of conception until actual death,” said State Senator Paul Wieland, a Republican who led the effort, adding that he did not “want any of my dollars going to pay for things that kill human life.”

The language prompted an uproar from female lawmakers. The governor called a special legislative session, and it was rewritten to bar public money from paying for “any abortifacient drug or device that is used for the purpose of inducing an abortion.”

National leaders of the anti-abortion movement say their next push will be to ban medication abortion — a two-pill regimen that terminates a pregnancy. Birth control “is not something that’s on our radar,” said Kristan Hawkins, the president of Students for Life of America, a leading anti-abortion group.

But like Mr. Wieland, Ms. Hawkins said she believed that I.U.D.s and the morning-after pill had been “mislabeled as contraceptives.” She added, “This is the ‘con’ in contraception.”

Since the leak last month of a draft opinion that would overturn Roe, some Tri-Rivers patients have been seeking intrauterine devices, which can stay in place for up to seven years, or to stock up on emergency contraception.

Anyone can buy Plan B at the clinic for $20, no prescription necessary. That is about half the sale price at Walmart, patients say. For Medicaid patients who cannot afford it, or who do not live nearby, Ms. Kramer can also write prescriptions, with Medicaid covering the cost — “at least for now,” she said.

Still, her patients are worried. Sydney Breedlove, a 23-year-old graduate student, said she had used Plan B twice, buying it at the clinic. When she was 19, she said, she bought it for a 16-year-old friend. She said some of her friends are stocking up, and some fear they will be forced to give up their I.U.D.s.

In the leaked draft opinion, Justice Samuel A. Alito Jr. emphasized “that our decision concerns the constitutional right to abortion and no other right.” Some legal experts have surmised that Justice Alito was seeking to send a message that the court was not trying to completely undo the right to privacy grounded in both Roe and Griswold.

But some Republicans are taking aim at Griswold nonetheless. Senator Marsha Blackburn of Tennessee has called the ruling “constitutionally unsound.” Republicans running for statewide office in Michigan and Arizona are echoing that language.

In the decades-long assault on Roe, advocates for reproductive rights see a blueprint for restricting access to contraception. After abortion became legal in 1973, opponents pushed successfully to chip away at the decision, partly by persuading courts and state legislatures to impose new requirements such as waiting periods and parental consent for minors.

“When are they going to start saying, ‘Just because you’re a 16-year-old woman, you can’t have access to this birth control or this service’?” Ms. Kramer said. “It concerns me that access will constrict.”