A favorite talking point for Republicans pushing to defund Planned Parenthood is that the services provided by the organization’s affiliates throughout the country can be easily replaced by federally qualified health centers (FQHCs): community clinics that receive billions in public funding to provide a range of primary health services to medically underserved patients.

House Speaker Paul Ryan (R-WI) says he wants to redirect Planned Parenthood’s funding to these centers, which he claims “provide the same kinds of services … without all of the controversy surrounding” abortion care.

But a Rewire investigation has found that some of these centers refuse to provide full family planning services, citing religious views.

“We believe that [life] happens at conception and that we don’t want to be involved in any type of procedure that would be an abortion,” said David Sanford, CEO of GraceMed, an FQHC with 13 clinics in Wichita and Topeka, Kansas.

Calling GraceMed a “Christ-centered ministry,” Sanford said that while his clinics provide many forms of birth control, they refuse to insert intrauterine devices (IUDs), even though the medical consensus is that IUDs prevent pregnancy and do not cause abortions, as Sanford claimed.

There is already overwhelming evidence that these centers could not replace Planned Parenthood. Much of that evidence, however, focuses on such centers’ capacity or their inability to fill the gap when it comes to specialized services that Planned Parenthood provides, such as sexually transmitted infection testing and treatment, as well as breast and cervical cancer screenings, in addition to comprehensive family planning.

Rewire’s analysis looked at the less-examined issue of religious imposition by the centers, which collectively receive billions in taxpayer funding annually to care for some of the country’s poorest and most vulnerable patients.

To assess the extent to which religious imposition is affecting the willingness of these centers to offer contraceptive care, Rewire called more than 100 federally qualified health centers across about 30 states, posing as patients asking about family planning services. Each FQHC is in fact an organization that may operate multiple facilities at different locations.

Administrators at seven of the FQHCs we called confirmed that the centers restrict delivery of family planning because of adherence to certain religious beliefs. An eighth center did not respond to our follow-up inquiries, but has publicized its religious opposition to most forms of contraception. Together, these centers operate health clinics in dozens of locations throughout the nation and collected $38 million in Affordable Care Act (ACA) grants last year alone. The total amount of taxpayer funding to these centers is much higher: Nationally, 20 percent of their revenue comes from federal grants, including through the ACA, while more than 40 percent comes from payments through Medicaid.

Five of these eight centers refuse to offer any contraceptive methods, or offer only education on natural family planning, citing Catholic religious doctrine. Two follow such restrictions only at certain sites due to leases with Catholic hospitals. The eighth was GraceMed, which received $5.86 million in grants under the Affordable Care Act in 2016. (Our survey was not scientifically randomized, and readers should not broadly extrapolate from these numbers.)

This imposition goes beyond contraception alone: GraceMed’s CEO said the center would refer patients seeking abortion to crisis pregnancy centers—the fake clinics run by anti-choice groups that do not provide abortions and mislead patients to deter them from abortion care.

Ironically, representatives at several religious health centers that refused to offer contraception referred Rewire to Planned Parenthood, an option that may no longer be available should Planned Parenthood be defunded.

Some centers Rewire called failed to refer elsewhere for the services they refused to provide, even though FQHCs are required by law to offer a wide range of care, including “voluntary family planning services,” and to refer patients elsewhere if they cannot or will not provide such services. The agency that oversees these health centers, however, does not define these services, other than to say they “include appropriate counseling on available family planning options.” In an email to Rewire earlier this month, a spokesperson for the Health Resources and Services Administration (HRSA), a division of the U.S. Department of Health and Human Services, said such services do not even necessarily have to include contraceptives.

Among the public health advocates who are calling for HRSA to issue stronger standards is Susan Berke Fogel, director of reproductive health at the National Health Law Program.

“If [Republicans] are successful in removing Planned Parenthood from federal funding … that’s all the more reason for federally qualified health centers to be held to a high standard in family planning,” Fogel said.

“We Don’t Do Family Planning Referrals”

With origins dating back to 1965, the roughly 1,400 federally qualified health centers cared for more than 24 million people across nearly 10,000 locations in 2015. These centers receive a raft of taxpayer aid, from enhanced payments for Medicaid and Medicare patients to federal grants and discounted drug prices. The ACA dramatically boosted funding to these centers, creating an $11 billion, five-year trust fund that was extended for two years in 2015.

The money set aside by the ACA to expand the centers’ operations and capacity amounts to less than 15 percent of their annual revenue, more than 40 percent of which comes from Medicaid payments. The rest is mainly from a blend of other grants, private insurance, and Medicare. However, data on these federal grants are publicly available for each individual center through USASpending.gov, so Rewire used these figures in our report.

FQHCs are required to serve all individuals, regardless of ability to pay. They are also required to offer, either directly or through referrals, a range of primary care services, from prenatal care to immunizations and children’s eye and ear screenings, as well as “voluntary family planning services.” Not surprisingly, given this broad mandate, nearly all FQHC sites focus on primary health care; only 7 percent of them focus on reproductive health, in contrast to 100 percent of Planned Parenthood health centers, according to the Guttmacher Institute.

Planned Parenthood is the sole source of publicly funded contraception for patients in some areas; they also offer shorter wait times for initial birth control visits, greater availability of evening or weekend hours, greater access to on-site oral contraceptives, and same-day insertion of contraceptive implants. More than 90 percent of Planned Parenthood health centers offer the full range of reversible, FDA-approved contraception, versus about half of FQHC sites, according to Guttmacher.

While many health centers may be unable to offer a full range of family planning services due to a lack of capacity, others deliberately refuse to do so for religious reasons. We identified five federally qualified health centers that deny contraceptive prescriptions as a matter of policy, citing Catholic doctrine.

They include Camillus Health Concern in Miami, Florida; Daughters of Charity Services of New Orleans in Louisiana; St. Jude Neighborhood Health Centers in Fullerton, California; St. Vincent de Paul Village Family Health Center in San Diego; and QueensCare Health Centers, in Los Angeles. (This story continues below the table.)

FQHC (Location)	Affiliation	Religious Restrictions	# of Health Clinics	What Representatives Told Rewire	ACA Grants FY ’16
Camillus Health Concern Inc. (Miami, FL)	Catholic	Refuses to offer all or most contraception	2	Family planning services are not offered.	$3.86 million
Daughters of Charity Services of New Orleans (New Orleans, LA)	Catholic	Refuses to offer all or most contraception	10	“This is a Catholic facility, ma’am. They don’t believe in birth control.”	$3.55 million
St. Jude Neighborhood Health Centers (Fullerton, CA)	Catholic	Refuses to offer all or most contraception	3	“We don’t offer any of that because we are a Catholic organization.”	$2.67 million
St. Vincent de Paul Village Family Health Center (San Diego, CA)	Catholic	Refuses to offer all or most contraception	1	“We don’t do family planning referrals.”	$997,053
QueensCare Health Centers (Los Angeles, CA)	Catholic	Refuses to offer all or most contraception	5	“Unfortunately QueensCare is Catholic-based, so they don’t give out birth control here.”	$3.75 million
Access Community Health Network (ACCESS) (Chicago, IL)		Rents one location from a Catholic hospital	36	“You could come in [for] an appointment and talk to a provider, [OB/GYN], and see what birth control options you have.” – Representative at ACCESS located at Holy Cross, where contraceptives are unavailable due to Catholic directives.	$14.26 million
Heartland Health Services (Peoria, IL)		Rents two locations from a Catholic hospital	5	“Some of the buildings, they’re owned through OSF (a Catholic healthcare network) and they don’t do birth control …. They don’t believe in that.”	$2.99 million
GraceMed Health Clinic Inc. (Wichita, KS)	Christian	Refuses to offer IUDs	13	“We do not [provide family planning referrals]. I do apologize.”	$5.86 million

“Unfortunately QueensCare is Catholic-based so they don’t give out birth control here,” a representative told a Rewire reporter, suggesting that the reporter could contact her insurance company for a referral, or, if she didn’t have insurance, Google Planned Parenthood or find a free clinic.

QueensCare, an FQHC that runs five health-clinic locations, confirmed in a statement that it follows the Ethical and Religious Directives for Catholic Health Care Services from the U.S. Conference of Catholic Bishops. These directives restrict access to a range of care, including contraception.

“Consistent with the values of the Catholic Church, QueensCare Health Centers provides high quality, holistic, compassionate care to the patients we serve,” the statement read. “Patients who wish to obtain contraceptive or any other services we do not provide are referred to other community health centers where the service is available.”

In a few other cases, health-center representatives initially refused to offer contraceptive services on religious grounds, only to have higher-ups later claim such services were, in fact, available.

That’s what happened at Covenant House New York, a homeless youth services organization with an on-site federally qualified health center. Its parent organization, Covenant House, is the largest privately funded charity in the Americas, according to its website.

“This is a Catholic organization, so unfortunately we’re unable to offer birth control,” a representative told Rewire, suggesting Planned Parenthood instead.

A spokesperson for Covenant House denied in an email that this is the organization’s policy, saying “medical staff meet the individual health care needs of youth, which includes contraception,” but Rewire received a similar denial when we called the New York location again.

Rewire received similarly conflicting responses when we called Herald Christian Health Center, another FQHC that serves a primarily Chinese-speaking population with three locations in Los Angeles County. Initially, a representative cited religion as a reason for denying care.

“So sorry we do not have [birth control], because we are a Christian clinic,” the representative said. She then suggested Planned Parenthood as a possible alternative.

The center’s CEO, the Reverend David Lee, denied its Christian identity prevents its doctors from prescribing contraception, saying it was possible the receptionist misunderstood the question.

“We’re Protestant,” he told Rewire in an interview. “We have no problem with birth control.”

Again, according to federal law, these centers must provide family planning services—however the government may define those—either directly or through “contracts or cooperative arrangements.” In practice, Sara Rosenbaum, professor of law and policy at George Washington University and a leading expert on FQHCs, said that means providing specific referrals.

“It has to be what the federal government would consider an established referral arrangement. You have to have a specific agreement [where] they will take your patients, because you are using somebody else to do a service that you’re required to do,” Rosenbaum told Rewire. “They can’t just tell you to go look in the phone book and find another provider.”

But some centers failed to comply with even that minimal requirement, at least during Rewire‘s initial phone survey.

A representative at Daughters of Charity Services of New Orleans, for example, indeed suggested checking the phone book for contraceptive services after telling Rewire the ten-clinic center does not believe in birth control. Administrators did not respond to requests for comment.

“We don’t do family planning referrals,” said a representative at St. Vincent de Paul Village Family Health Center in San Diego, part of Father Joe’s Villages, the city’s largest homeless services provider.

In a written statement to Rewire, Ruth Bruland, chief program officer at Father Joe’s Villages, claimed the organization does in fact provide referrals, a policy that arises from its refusal to offer contraception based on religious beliefs.

“Like many other homeless services providers, utilizing the referral process does arise out of our agency’s Catholic heritage,” Bruland said.

Administrators at St. Jude Neighborhood Health Centers and Camillus Health Concern both confirmed it is also their policy to refuse to provide contraception, but also said they refer patients elsewhere.

When Restricted Access Results in Unintended Pregnancy

One case in Illinois shows how religious restrictions can block access to care for some patients who rely on federally qualified health centers—with life-altering consequences.

Providers at Heartland Health Services, an FQHC in Peoria, Illinois, cannot prescribe contraception at two of the health center’s five locations in the city because Heartland rents those two spaces from a Catholic health network called OSF Healthcare. (OSF stands for Order of St. Francis.)

The CEO of Heartland, Charles Bandoian, said the leases—and their accompanying religious restrictions—were in place before he became CEO.

“I think knowing what I know now I would just try to make arrangements where we’re not on Catholic property or there are other arrangements that we can make somehow to get around this,” Bandoian told Rewire in a phone interview.

Those restrictions have caught the attention of the American Civil Liberties Union (ACLU) of Illinois, which sent a letter to the health center last Monday laying out its concerns, and provided a copy to Rewire.

While Heartland claims contraception is available at all three sites that are not owned by OSF, the ACLU letter says people who called Heartland’s appointment line posing as patients earlier this year were told they could only get contraceptive prescriptions during a two-hour window on Thursday afternoons at a single site in the East Bluff neighborhood of Peoria.

The ACLU also claims that one patient became pregnant after she was denied a birth control prescription at the site nearest to her home. The patient was unable to visit the East Bluff site on Thursday afternoons, the letter says.

In addition, the ACLU argued that Heartland’s restrictions may be exacerbating racial health inequities in an area where Black teens give birth at more than five times the rate of their white counterparts, data show.

Heartland’s director of marketing, Jamie Messmore, said that while Heartland’s East Bluff site hosts a family planning clinic with expanded staffing twice a week, including on Thursday afternoons, patients can access contraception at all three Heartland sites that are not subject to Catholic directives whenever those locations are open. One of those three sites is a behavioral health center that focuses mainly on mental health services.

“We appreciate the ACLU’s inquiry,” Messmore told Rewire in an interview. “It’s something that we’re taking seriously, so that we can do a better job to address the needs of the public because that’s certainly what we’re here to do.”

These frustrations were not limited to Illinois. Rewire heard similar concerns from Dr. Daniel Moring-Parris, who was forced to follow certain Catholic restrictions during his family medicine residency between 2010 and 2013 at O’Connor Hospital in San Jose, California, because the hospital was run by the Daughters of Charity Health System at that time.

Moring-Parris said he was barred from inserting long-acting contraceptives, including IUDs, at his residency clinic near the hospital building, but sent patients to another clinic right across the hall.

Even this seemingly simple arrangement became a roadblock to providing care, said Moring-Parris, particularly because the other clinic required patients who wanted an IUD to have a pregnancy test two weeks before insertion of the contraceptive.

“Often [patients] didn’t really understand that they were coming back across the hall, so they would wait in our clinic and then miss their appointment across the hall, and then get rescheduled,” Moring-Parris told Rewire. “It resulted in a lot of people who probably would have easily gotten an IUD in clinic that day then never getting one because it was just too logistically annoying.”

The clinic where Moring-Parris worked was operated by an FQHC beginning in 2012, but O’Connor residents stopped following Catholic restrictions at the site only after a hedge fund took over the hospital in 2015. They were ecstatic.

“All of the residents were so excited for this change, I mean, we were just beaming,” former resident Dr. Tamara Montacute told Rewire. “We were so happy to be able to provide our patients with these services that we knew they needed and wanted.”

“It’s Outrageous That Birth Control Is Even on the Table”

The fate of federal funding for FQHCs remains uncertain amid the continuing debate over the future of the ACA. However, the centers have long found support from politicians on both ends of the political spectrum, from Sen. Bernie Sanders (I-VT) to President Trump’s newly confirmed Health and Human Services secretary, Tom Price, who recently said FQHCs “play a vital role in our nation’s health-care delivery system.”

But the centers cannot come close to meeting the needs of the millions of patients who rely on Planned Parenthood for contraceptive care—particularly as the need for publicly funded contraception is growing.

“In 2014 there were just over 20 million women who needed that care, which was about a million more than in 2010,” Kinsey Hasstedt of the Guttmacher Institute, told Rewire in an interview. That increase, she said, “is largely driven by adult women who have low incomes or are living in poverty.”

Those patients rely on a health-care safety net that includes Planned Parenthood—but even as needs increase, Congress and the Trump administration are gearing up to slash that safety net.

Compounding concerns is the expectation that religious imposition in health care of the sort uncovered by Rewire could increase under the Trump administration. While religiously affiliated health centers reached by Rewire now claim they are meeting the letter of the law by referring patients elsewhere for family planning services, an expanded interpretation of the Religious Freedom Restoration Act (RFRA), for example, could allow FQHCs to opt out of the federal family planning requirements altogether.

Such a scenario “should be unthinkable,” Susan Berke Fogel of the National Health Law Program told Rewire. “It’s outrageous that birth control is even on the table when it is such an essential, basic health service for millions and millions of people.”

Brie Shea contributed to this report.

Tell us your story. Have religious restrictions affected your ability to access health care? Email [email protected]