Even as a national debate rages over contraception insurance, tens of thousands of low-income women and teenagers across the United States have lost access to subsidized birth control as states slash and restructure family planning funds.
Montana and New Jersey have eliminated altogether their state family planning programs. New Hampshire cut its funding by 57 percent and five other states made more modest program trims.
But the biggest impact, by far, has been in Texas.
State lawmakers last fall cut family-planning funds by two-thirds, or nearly $74 million over two years. Within months, half the state-supported family planning clinics in Texas had closed.
The state network, which once provided 220,000 women a year free and low-cost birth control, cervical cancer tests and diabetes screenings, will now serve just 40,000 to 60,000, officials said.
Another 130,000 low-income Texas women who get free exams and contraceptives through Medicaid could lose those benefits by month's end, due to a dispute between the state and federal governments over whether Planned Parenthood should be allowed to serve women on that program.
At the People's Community Clinic in Austin, the cuts mean that many low-income patients, except the very poorest, are now charged for contraception that used to be free: $5 for a dozen condoms; $10 for a month of birth control pills; $225 for an IUD.
"I have no clue what I'm going to do," said Rhetta Pope, 22, of Austin. A stay-at-home mother of two, she lives off disability payments of less than $1,500 a month.
Pope said after paying basic living expenses, she has so little left she scrimps on electricity by keeping the lights off and takes her laundry to an aunt's house. She can't imagine how she would pay for birth control.
"I guess I'm going to have to stop using it because I don't have the money," Pope said. "I'm pretty shook up. I really am."
SAVINGS IN DOUBT
Texas legislators who backed the 66-percent family planning cuts say they had no choice - the state budget was in crisis and many worthy programs suffered.
But a budget board analysis concluded the cut would actually cost Texas taxpayers more than it saved.
The board projected that women unable to get low-cost birth control would deliver 20,500 additional babies - costing state and federal taxpayers $231 million in prenatal, maternity and infant care. The state's share would be close to $98 million - significantly more than the family planning cut savings.
State Representative Wayne Christian, a Republican, acknowledged that the cuts might be counterproductive "if you look at it from a financial cost, perhaps."
But he disputed the notion that additional babies were a cost burden. "We value a human life more than just the cost," he said.
In general, he said, the state should not try to deter births by widely distributing free contraception. If women who want birth control cannot afford it, he said, they should first seek help from families or communities.
"I'm sorry," Christian said, "but there's this thing called individual responsibility."
Some women have found ways to pay for the care they once received free, but many have not.
After losing much of its state family-planning grant, the Parkland Health & Hospital System in Dallas in January began charging most patients a flat $25-per-visit fee.
In the first two weeks of the policy, 362 women cancelled appointments because they could not make the co-pay. Only 20 percent found the money to get care within a week or two, hospital officials said.
Another 20 percent were referred to one of the two Parkland locations still providing free services. Those sites are now so busy, the first available appointment at the Irving Women's Health Center is August 21.
Most of the remaining women never came back for care after learning about the co-pay, said Paula Turicchi, a Parkland senior vice president.
BLOCKING TAXPAYER DOLLARS
In several states, including Texas, questions about birth control access are now entangled with the politically explosive abortion debate.
Planned Parenthood is the nation's largest abortion provider, with about 330,000 procedures a year. It also runs a network of urban and suburban clinics offering birth control, gynecological exams and care for sexually transmitted diseases.
The organization gets about a third of its revenue, $360 million in 2009, from government grants to provide those services to poor women.
In the past year, Wisconsin, North Carolina, Tennessee, Indiana and Texas all have moved to block Planned Parenthood from receiving taxpayer money. Several other states, including Ohio, Oklahoma and New Hampshire, are considering similar moves.
While public funds don't pay for abortions, critics of Planned Parenthood argue that hiring the organization to provide family planning to poor women helps the organization stay afloat and thus indirectly supports abortion services.
The Texas funding cut prompted Planned Parenthood to shut down 11 clinics. It also has jeopardized a $40 million family-planning program run as a Medicaid extension.
The program provides free birth control and annual exams to 130,000 low-income women of reproductive age who don't qualify for regular Medicaid. The federal government pays 90 percent of the cost; Texas puts up just $4 million a year.
About 40 percent of women in the Texas program get subsidized care from Planned Parenthood clinics, but a new state law blocks those clinics from participating. The Obama administration has said that violates federal Medicaid rules. If neither side compromises, the program will likely close by the end of March.
That infuriates Jonee Longoria, a single mother in Houston who relied on the program for free services for several years as she put herself through college. "I had one child living in poverty and I didn't want another," Longoria said.
She now works for a social service agency and refers many clients to the program for contraception. Without it, she said, "where would they go?"
Advocates of defunding Planned Parenthood say they regret any service disruptions for poor women. But they call it a necessary price to pay to take a moral stance on abortion.
"We're just doing what we think is best," said Joe Pojman, executive director of Texas Alliance for Life, which opposes abortion.
(Editing by Marilyn W. Thompson and Xavier Briand)