By Claire Carlson for The Daily Yonder.
Broadcast version by Emily Scott for Big Sky Connection reporting for The Daily Yonder-Public News Service Collaboration

Reproductive rights activists who are fighting abortion restrictions in Montana say new state laws will have a disproportionate impact on reproductive care in rural communities.

The laws, currently awaiting a Montana Supreme Court decision, prohibit abortions after 20 weeks, require providers to offer ultrasounds to patients, and prohibit medication abortions via telehealth and mail prescriptions.

The telehealth and mail-prescription bans could have the biggest direct impact on the state's dispersed and remote rural populations, but all three laws work together to limit abortion services statewide, especially for underserved and rural populations, abortion rights advocates say.

"Each of these bills have their individual impacts, but together, they do what I call the 'squeeze,'" said Martha Stahl, CEO and president of Planned Parenthood of Montana. "They work together to make it a much more difficult process to access care early in pregnancy, which, for abortion patients, is something that people need in a timely manner."

Republican Governor Greg Gianforte signed four abortion bills into law in April. The only one currently in effect prohibits health insurance plans that are covered by the state's health insurance exchange from paying abortion expenses.

Planned Parenthood of Montana is suing the state of Montana over the bills, arguing that they breach Montanans' constitutional right of privacy.

"Legal precedent exists in a couple of places that actually show the court's belief that that right to privacy is directly applicable to access to sexual and reproductive care and to abortion," said Stahl.

District Judge Michael Moses put the three laws on hold just hours before they would have gone into effect in October to give the court time to consider Planned Parenthood's legal challenge.

The bill that most clearly affects rural communities is HB 171. Medication abortion by mail and telehealth consultation is often the only way an abortion seeker can receive care if they live in remote areas and don't have the ability to travel long distances for medical care.

However, abortion providers do recognize that this option doesn't guarantee access for everyone.

"Telehealth isn't always the amazing solution that it seems for rural America, simply because people's lack of broadband can get in the way," said Stahl. "But now that providers can actually bill insurance for these services, it really has changed the face of access for a lot of folks."

Telehealth services also include site-to-site patient care, which allows a patient to go to their nearest health center and connect via telehealth with an abortion clinic elsewhere to be prescribed medication abortion. This brings telehealth to people without broadband, but along with medication abortion by mail, this site-to-site patient care would also be banned under HB 171.

According to Planned Parenthood, medication abortion provides two medicines: mifepristone and misoprostol. These pills are taken within two days of one another and induce cramping in the uterus, creating a process similar to an early miscarriage. In Montana, medication abortion can be given up to 11 weeks after the last day of the person's period. The process is safe, effective, and common.

Between July 1, 2020 and June 30, 2021, Planned Parenthood of Montana provided 935 medication abortions and 255 procedural abortions, according to data from the organization. Of these medication abortions, 140 were direct-to-patient, meaning they were mailed. Had these patients been required to show up in person, 56% would have had to drive one to two hours one-way to reach the clinic, and 18% would have had to drive two to five hours one-way, according to Planned Parenthood.

In a state as large as Montana, being required to drive to a clinic can be a significant obstacle, which is why many patients use telehealth and direct-to-patient mailing services. Snow and icy road conditions in the winter can make drives even longer, which is another reason abortion providers say telehealth services have revolutionized abortion access for rural communities in the state.

There are just three abortion providers in Montana: Blue Mountain Clinic, All Families Healthcare, and Planned Parenthood. Their clinics are primarily concentrated in the western part of the state, which means that if patients were required to drive to an abortion clinic for in-person care, those living on the far eastern side of Montana could be forced to travel between seven and eight hours one-way.

(The Daily Yonder driving-time analysis at the top of this article is based on Google Maps estimates, which do not account well for terrain or road conditions in many rural areas. The Daily Yonder found that residents of eastern Montana were likely to drive five to 10 times longer to reach abortion services than residents of unserved counties in western Montana.)

By banning direct-to-patient medication abortion by mail and site-to-site care, people in rural areas without reliable transportation are left with few options.

This is where support from abortion organizations like the Susan Wicklund Fund can help.

The Susan Wicklund Fund is one of only two abortion funds providing financial support to people in Montana - the other is Indigenous Women Rising's fund, which supports Indigenous and undocumented people. Both of these funds rely on donations, usually from individuals, and the Susan Wicklund Fund is fully volunteer-run.

According to Kate Kujawa, chair of the Susan Wicklund Fund, the organization provides their callers with support with transportation costs and medical expenses. The fund provides support to anyone in Montana, even if they travel out of state to go to an abortion clinic. Activists say this might become increasingly common, even if the bans aren't enforced.

"We wouldn't be shocked if privacy and medical privacy is stripped in Montana," said Kujawa. "And if that happens, we do believe that abortion will become harder to obtain, and at that point, we are prepared to help people get out of state or out of country depending on what is easiest and best in order to help them retain their access to choice."

If the bans do go into effect, Kujawa believes they will only magnify financial and social disparities between abortion seekers. "If you don't have access to a car, if you can't coordinate childcare with family or friends, you're really just left without options," said Kujawa.

Requiring in-person care isn't the only issue activists believe will affect rural communities.

Stahl, of Planned Parenthood, is also concerned about HB 171's requirement for abortion providers to make public the demographics of their patients. The law would require clinics to report the patients' age, race, and number of previous pregnancies.

"If you think about Montana that has rural counties of less than 1,000 people, [being able to identify] a patient who's, say, been pregnant three times and is 24-years-old is not going to be that difficult for the people living in that county," said Stahl.

While HB 171 has the most direct impact on rural communities, all three bans work in concert to restrict rural access, according to Stahl. HB 140 requires in-person appointments so people can be given the opportunity for an ultrasound, and HB 136's 20-week ban decreases the amount of time a person has to get an abortion. If a person has to get an abortion before they are 20 weeks pregnant and they are required to drive to multiple appointments across state for in-person care, the process is challenging.

Some argue that complicating this process is the goal for Republican lawmakers who are closer to restricting abortion in Montana than they have been in years. This is thanks to Republican Governor Greg Gianforte, who was elected in 2020 after 16 consecutive years of Democratic governors.

"Republicans have the majority and are using these abortion access restrictions to demonstate their power and to fire up their voting base," said Helen Weems, nurse practitioner of All Families Healthcare, one of the three abortion providers in Montana, in an email.

Supporters of the bills believe these restrictions are a step in opposing Planned Parenthood as a whole, which has long been targeted by anti-abortion Republicans. Along with abortion services, Planned Parenthood provides other affordable reproductive health services - many to low-income or underserved communities - such as STD screening, contraception, and preventive reproductive care.

A state lawmaker who supports the restrictions said the measures would not affect health care services for rural areas.

"How can you call aborticide a health issue?" said state Representative John Fuller (R-8) from Whitefish, in northern Montana. "Banning aborticide through mail or through telehealth is not reducing health care to rural America [or to] rural Montana."

Reproductive rights activists say that these bills wouldn't stop abortion but would only stigmatize the procedure and put undue burden on low-income and rural communities.

There is no end date to the court injunction that halted the bills in October, which means that until the Montana Supreme Court makes a decision, abortion seekers won't face the restrictions the bills would enact.

"These laws do not represent the will of the majority," said Weems. "We will keep fighting and keep caring for our patients. We aren't going anywhere."

Claire Carlson wrote this article for The Daily Yonder.



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A new report found New York hospitals are in a precarious financial state.

The New York State Hospitals Fiscal Survey Report showed statewide hospitals are projecting an operating budget margin of 0.0% percent. While it is a slight improvement, hospital administrators said it is still insufficient for hospitals to handle patient care.

Bea Grause, president of the Healthcare Association of New York State, said government reimbursements do not cover the costs of administering health care.

"Those reimbursements are fixed and do not change," Grause pointed out. "They grow a little bit year over year but they're not keeping up with the expense growth that all hospitals are experiencing."

She noted hospitals cannot raise their commercial expenses with the expectation it will make up the difference, arguing the best way to help hospitals is to close the gap on Medicare and Medicaid payments so they keep up with expense growth. Prescription drugs are the largest continuously increasing expense hospitals face since such prices run 83% above the rate of inflation.

Staffing issues are being exacerbated by New York hospital's fiscal challenges. The report found labor expenses have grown more than 36% since 2019. While it is the second year of declining contract labor expenditures, they are double what they were in 2019.

Grause emphasized not having sufficient staff can affect the services hospitals offer.

"If a hospital is going to have a dialysis unit, you need a nephrologist. You'd probably need more than one nephrologist," Grause observed. "But you also need specially trained nurses, you need the right equipment, you need all the medication, you need the IV solution and the peritoneal solution."

Another factor in hospitals' declining operating margins is insurer demands. The report showed some surveyed hospitals project insurers' actions will cut their 2024 operating revenues by 5% or more. Estimates showed it would result in $1.3 billion or more in lost revenue for the hospitals.


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More than half of North Carolina counties have fewer than four dentists per 10,000 people and a few counties have no dentists at all.

The North Carolina Dental Society Foundation is stepping up to meet those residents where they are, for essential dental services.

Dr. Amanda Stroud, dental director and chief dental officer for AppHealthCare and a member of the foundation board, said she sees the need firsthand. She explained the biggest barriers are lack of dental insurance, affordability and the ability to get timely appointments.

"It may be that someone has to wait six to nine months for a dental appointment when they may be having tooth pain," Stroud observed. "And it may be that once they get that appointment, that appointment's just for a planning process and not always something that can help treat the pain or manage the dental issues."

Stroud noted such challenges affect a significant number of people, particularly in rural parts of the state. So, the foundation supports programs like "Give Kids a Smile" and the "Missions of Mercy" clinics, to provide free oral health services.

Stroud emphasized the events are supported by fundraising efforts, like an annual golf challenge. Dentists from across the state volunteer to perform extractions, fillings and cleanings and sometimes offering lifesaving care.

"You can have a dental infection that becomes something that is a cause of death for the patient," Stroud pointed out. "And that's happened in the United States. And you don't want to think about that happening in the United States, but it has."

Sharon D'Costa, fund development and program director for the foundation, said the efforts so far have reached nearly 73,000 patients. Beyond direct care, she stressed they are helping to expand the dental workforce in the state.

"We're working with community colleges to kind of provide students with scholarships," D'Costa outlined. "We're also initiating new programs, we're incentivizing faculty to stay in their jobs as well as get new faculty to take on roles teaching dental assisting and dental hygiene students."

D'Costa added the foundation awards grants and recognizes public health efforts to improve access to dental care. She acknowledged it is challenging to mobilize volunteers and secure funding but strong community partnerships help the foundation improve its impact.

Access to reduced-price medication is vital for many low-income rural Tennesseans and the clinics serving them are concerned about potential cuts to a program that helps with drug costs.

The 340B program allows safety-net providers, like community health centers, to purchase outpatient medications at discounted rates.

Emily Waitt Hise, policy and advocacy manager for the Tennessee Primary Care Association, said the savings are crucial.

"The 340B program allows health center patients to receive the care they need to attain their highest level of health," Waitt Hise asserted. "It ensures that all patients can receive the lifesaving medications they need to manage chronic conditions, like diabetes or high cholesterol."

She pointed out health centers are required to reinvest the savings from the program back into patient care, which helps them provide other services like pediatrics, behavioral and dental health and OB/GYN care. Health centers are concerned that the 340B program will be on the chopping block under the new administration.

Laura Harris, CEO of Chota Community Health Services, said the 340B program offers significant cost savings, which are passed on to low-income and uninsured patients. She noted the costs vary by drug but are generally minimal. Her organization did a recent patient survey, confirming the cost savings.

"This third patient said, 'Eliquis was going to cost me $500, because my insurance denied it. With the program, it only cost $50,'" Harris reported. "A fourth patient said, 'My inhaler was over $100, but I got it for $25.'"

Harris argued the biggest challenge with the program is the pharmaceutical manufacturers' contract pharmacy restrictions, which limit 340B pricing to one pharmacy. She added it forces patients on multiple medications to visit different pharmacies to fill their prescriptions, which is challenging in rural areas.