When Ashley Smith arrived to testify before the Maine Legislature during a committee hearing last spring, she was terrified. "I was shaking like a leaf in the wind," she says.
She told lawmakers that she was there in support of Maine Family Planning, a 50-year-old network of reproductive health clinics where Smith is a patient.
State lawmakers were considering how to make up a funding shortfall from Washington, D.C. where Republicans in Congress aimed to cut off federal funding to clinics that provide abortion.
Smith told the committee that she doesn't have health insurance and that Maine Family Planning's nonprofit clinics were her only source of health care.
"In the last four years I've received care there, not once did I have an abortion," Smith testified. "I did, however, have access to STD and STI (sexually transmitted disease and infection) testing, referrals for thyroid testing and blood panels, pap smears, breast examinations, referrals for mammograms, and a premenstrual dysphoric disorder diagnosis. The last two I listed saved my life," she said.
Smith, who's 36, says she was inspired to testify and write an op-ed, because she's worried about what would happen if Maine Family Planning had to close in the face of deep federal funding cuts. "I can't imagine what would happen to our communities if we lost such a keystone — that's what really fueled my fire," she says.
Maine Family Planning did get a year of additional funding from the state, but it also lost Medicaid revenue for one year with the passage of President Trump's tax and spending bill — a 20% hit to the organization's funding.
The "defund" effort beyond Planned Parenthood
In Maine, abortion is legal and widely supported by the electorate. In a poll released by the Pew Research Center this summer, 72% of Mainers say abortion should be legal in all or most cases. The state legislature has moved to expand access to abortion care since the Supreme Court overturned Roe v. Wade three years ago.
Now, the Trump administration and congressional Republicans are using federal funding as a lever to restrict abortion access in states, like Maine, where it is legal and protected by state law.
Republicans and anti-abortion rights activists have long sought to end Medicaid dollars flowing to Planned Parenthood for any reason, arguing that federal reimbursement even for unrelated services indirectly supports abortion in clinics that specialize in reproductive health. In July, they were finally able to accomplish that goal.
The provision in the law blocks federal Medicaid funds from being paid to reproductive health nonprofits that receive more than $800,000 in Medicaid payments in a year. It took effect when the bill was signed by President Trump on July 4. (Republican senators changed the timeline from a decade to a single year of defunding to comply with Senate rules.)
Very few organizations fit the $800,000+ description. Planned Parenthood is one of them, another is Health Imperatives in Massachusetts, and so is Maine Family Planning.
"Where am I going to go?"
About half of Maine Family Planning's patients are on Medicaid. The organization is no longer reimbursed for their visits.
That's about $2 million gone, says George Hill, Maine Family Planning's president and CEO.
"That's difficult. You have to make some difficult decisions," he says. "Either you generate more revenue, or you cut costs."
On Oct. 1, the organization let patients know they would be ending primary care services at the end of the month at three clinics in the far reaches of the state: Houlton, Presque Isle and Ellsworth. That change affected nearly 1,000 patients, including patients on Medicaid and those with private insurance.
"The day that our portal message went out [to patients], the phones just started ringing off the hook," says clinical services director Melissa Gray. "It was the same message over and over again: 'Where am I going to go? You folks have helped me with things that nobody else had helped me with, I never felt like you were judging me. I don't want a different provider, I want to keep seeing you.'
"It was really heartbreaking and a hard couple of days for staff," she says.
Gray and her team spent all of October trying to connect those patients to new doctors, and making sure they were set up with enough refills of medications to last them when there were long waits before they could be seen by the new practice. Maine has a health care provider shortage, which made that task harder, she says. "There already weren't enough providers — we were getting new patient requests all the time," she says. "Now there's less."
The goal of scaling back primary care was to try to preserve family planning for longer. All 18 of their family planning clinics around the state are still open. "We have a mission," explains Hill. "And our mission is to make sure that the full range of sexual and reproductive health care is available to as many patients as possible."
They're still seeing Medicaid patients for sexual and reproductive health without getting paid for it.
A stack of billing sheets, just in case
One of their clinics is in Thomaston, Maine, a small town along the coast. Vanessa Shields-Haas is the nurse practitioner there. The clinic is bright and friendly, with colorful "condom art" on a bulletin board in the waiting room.
Shields-Haas is infuriated by the funding cuts to Maine Family Planning and what they mean for her patients.
"A lot of my patients — maybe they're working at a hotel or they're waiting tables, they're serving lobster rolls to hungry tourists, starting oyster farms," she says. "These are people that are working really hard."
She does a lot for them: fertility treatments, biopsies, prescription refills, even vasectomies. And she's continued to do all those things for her patients covered by Medicaid without getting reimbursed.
"We haven't been turning them away," she says. "I fill out the billing sheets and we stack them up in the event that we could be reimbursed possibly in the future."
She says patients are confused by what's happening, and many have sent her messages asking if they can still go to her for care. She assures them that they can, although she worries about the future.
"Unfortunately, decision-makers in Washington are having such a profound impact on what we can and can't do," she says. "Not being able to be reimbursed for the visits is really crippling, financially."
A legal challenge
For George Hill, political interference in sexual and reproductive health care is nothing new. "I've been in the field since 1987, so close to 40 years, [through] several different presidential administrations that have been hostile to the care that we now provide," he says. "This is — by volume and velocity — probably the worst that we have seen."
Just weeks after the One Big Beautiful Bill Act was signed into law, Maine Family Planning filed a lawsuit to challenge the provision that blocks them from getting Medicaid funding.
"The lawsuit was filed essentially because Maine Family Planning says this is unfair and it's wrong and it's unconstitutional to be singling out and targeting certain providers based on this animus against abortion," says Autumn Katz, interim director of litigation at the Center for Reproductive Rights, which represents the organization in its lawsuit.
The federal government defended the provision in a court filing, arguing that it promotes Congress' "goal of reducing abortion" and suggesting Maine Family Planning could get its funding back if it stopped providing abortion.
(Planned Parenthood filed a separate lawsuit and was able to secure an injunction. In Maine, the injunction request was denied and so the provision is in effect while the lawsuit works its way through the courts.)
Another threat looms
Anti-abortion efforts at the federal level may not stop with the Medicaid law.
Another 20% of Maine Family Planning's budget comes from the federal government through Title X — a decades-old grant program that enables the clinics to see uninsured patients. In October, the Trump administration fired the whole team that works on that program. Those firings were reversed in mid-November as part of the deal to end the shutdown, but the administration could try to end the program in another way.
Hill says he isn't sure what's going to happen next with the lawsuit and Medicaid, or Title X, but he says they're not giving up. The state law that patient Ashley Smith advocated for provides short term funding from the state to help fill the budget gap. Hill says they're exploring new potential partnerships and new ways to raise revenue they haven't tried before.
He quotes Rep. Pat Schroeder, the late Democratic lawmaker from Colorado: "You can't roll up your sleeves and get to work if you're wringing your hands," he says. "We're going to continue to do the work. We're not going to stop."
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