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BROWNWOOD — Women come from more than one hundred miles away to Building 35 in a red brick public housing project in rural Brown County, a housing unit turned health clinic where virtually every item, even the beige exam tables, is donated.

The clinic is walk-in only — no appointments — a better bet for patients with unreliable transportation or unpredictable schedules. Without federal funds, Midway Family Planning in Central Texas would have shut its doors long ago, its director says, as state budget cuts dried up family planning dollars from the Gulf Coast to the Texas Panhandle.

Instead, the nonprofit clinic has endured as a small health care lifeline, where low-income and uninsured Texans — far from busy cities with many doctors — can get free or low-cost contraceptives, cancer screenings and treatment for sexually transmitted diseases.

This is what women’s health care looks like in the rural heart of Texas, a state routinely ranked among the worst nationwide in health care access and where three-quarters of counties lack enough medical professionals.

Lawmakers have increased funding for women’s health in recent years, but there remain large swaths of the state where medical professionals are scarce and reliable internet is spotty — and the gap between these health care have-nots and their urban counterparts has widened during the coronavirus pandemic.

From the rural Panhandle to the U.S.-Mexico border, financial pressures and safety concerns have shuttered doctors offices, inundated health departments and pushed people living on slim margins into ever more precarious living situations.

Some clinics have seen their office visits plummet, leaving experts to wonder if women are missing opportunities to catch potential health problems before they need serious treatment. Elsewhere, safety net providers like Midway have scrambled to see patients traveling further to get time-sensitive care, like birth control.

While clinics in cities like Dallas and Houston easily pivoted to telehealth visits to minimize face-to-face contact when the pandemic hit, that prospect makes Midway’s director, Carole Parker, laugh: Most of her patients don’t have access to stable internet connections.

“It’s just not feasible. We don’t do anything online,” she said. “Where we are, that is just not an option for us.”

Midway runs a three-exam-room clinic on an annual budget of roughly $198,000, at least half coming from the federal government. It’s staffed three days a week, with two contracted nurses, an administrator and Parker. A nurse practitioner and a local obstetrician-gynecologist with a busy private practice drop in.

Nearly all the 1,100 patients they served last year lacked insurance. Many don’t have permanent homes, and though the state has a health program for low-income women, it has limited use here. Parker knows of just one other health center and an obstetrician-gynecologist’s office around Brownwood that accept payment through the program.

After a lull during the spring, the Midway clinic became “run over” with demand this summer, Parker said, as the coronavirus has devastated parts of the state’s economy and sent unemployment claims skyrocketing. Some patients describe desperate challenges to find reliable housing and work.

Some patients are newly unemployed, have just lost job-based insurance or are driving more than an hour to Midway. Parker says the clinic has gone from serving people in three counties to about a dozen, and believes people are commuting further because nearby clinics and doctor’s offices scaled back their services or succumbed to the loss of revenue that accompanied the delay of nonessential procedures this spring. Others have diverted staff to focus on the coronavirus or have personnel out quarantining after being possibly exposed.

It’s “just become a greater burden on the people that are still able to provide services,” said Parker, whose clinic also treats homeless women and those in the local shelter for people fleeing abusive relationships.

In September and October, there was a marked increase — 27% more than the same period last year — in undocumented people coming to the clinic after cross-border traffic was restricted, she said. Several women had serious conditions, like a mass in their breasts, when they arrived, a problem for Parker because she said there are few places to refer them for advanced care if they cannot pay.

“I don’t know if they thought it would be over so they let their condition ride through the summer, but by the time they got here, it was almost an emergency situation,” she said. “There was apparently nowhere they could go if they had no money to be treated.”

A health care lifeline

On a summer Monday, the raps on the Midway clinic’s door come often. Down the street from a bail bonds center, the clinic is in the predominantly white city of Brownwood, which counts manufacturers like 3M and Kohler as major employers. The city’s median household income is far lower than the state’s overall, and about a fifth of its 18,500 residents live in poverty.

Judy Guinn, the clinic’s manager, slips on a plastic face shield and opens the clinic door. In a small community like Brownwood, many of the faces are familiar.

“All I see is your eyes, I can’t see your pretty face,” she tells the masked woman outside, a high school senior whose parents were incarcerated while she was growing up.

The woman, a minor, is here to get a birth control shot, which prevents pregnancy for three months. The next woman who walks in — with “Midway Family Planning” scrawled on a pink sticky note stuck to her finger — says she’s there for contraception and doesn’t have insurance. She lives nearly an hour drive away. Another walks in to pick up a pack of birth control pills.

Most of the clinic’s patients are between ages 14 and 30. Parker said many of the teenagers that come have absent parents or an unstable home life, and some are comforted by the nonjudgmental approach taken by the clinic staff.

Bethany Wigham started coming to Midway Family Planning when she entered her first relationship in high school. She didn’t feel like she could talk to her family and wanted to get medical advice and birth control without her parents knowing.

Clinic staff helped her apply to the state’s health program for low- and middle-income women once she turned 18 and once kept the clinic open late for her to pick up medication after coming back into town from school, she said.

“It was the only place I could find in the area that would let me go at 17 without my parents,” said Wigham, who is now studying pre-clinical psychology at Tarleton State University. “I was able to go [see] them and have a talk with all these questions, that I didn’t have anybody at home to really help me.”

First: Judy Guinn, office manager at the Midway Family Planning clinic in Brownwood. Last: Bethany Wigham, a 20-year-old student from Tarleton State University, drove 60 miles from Stephenville to visit the Midway Family Planning clinic. Credit: Jordan Vonderhaar for The Texas Tribune

When the pandemic hit, closing the town’s only movie theater, the clinic closed for several days. Its staff knew they couldn’t rely on unstable Internet connections for telehealth visits, and instead found a low-tech alternative: They popped open a window and began dispensing birth control pills through the opening and curbside.

Women coming for contraceptive shots or for a preventive screening were told to enter through the back door of the clinic, see the nurse and exit through another door to minimize face-to-face contact from two-way foot traffic. One person was permitted to enter the clinic at a time. Parker and her staff sometimes held babies so mothers unable to find child care could go in for treatment alone.

The clinic is eccentrically decorated, though it bears the unmistakable hallmarks of a small one-story house. Guinn perches at a counter right next to the refrigerator — in what would be the unit’s kitchen — where she calls patients and reminds them they are due to come in for their birth control shots. A crate of patient files sits on a narrow counter behind her next to the kitchen sink.

The bedrooms have been converted into offices and exam rooms and have colorful gauze hung from the window blinds. The patients’ bathroom has a large potted plant in the bathtub. Medications are stocked in locked wood and glass armoires— a small pharmacy the clinic operates thanks to a federal drug program that offers medications at a reduced cost.

Many of the clinic’s patients come from the housing authority that houses it, subsidizing its rent and utilities. The rest of the clinic’s funding is cobbled together from grants, government programs and donations. Packs of condoms were a gift from the county health department and a state infertility project. Prescriptions and long-acting reversible contraceptives are subsidized by a federal program that provides affordable birth control and reproductive health care to poor people.

Parker relies heavily on federal funds rather than state appropriations, which she’s found to be too volatile a funding stream in Texas, where lawmakers have been tight-fisted with women’s health funding in the past.

The clinic used to receive a significant amount of money from the state in the early 2000s, but as anti-abortion sentiment swelled, the funds dried up, she said. In 2011, the Texas Legislature slashed funding for family planning by two-thirds and restructured it to starve clinics like Planned Parenthood. Midway’sfunding was decimated. For a few years, the clinic “survived on donations,” Parker said.

Women’s health providers around Brownwood — in San Saba, San Angelo and Abilene — closed under the financial stress. It was a blow for Parker, who used to send patients to those areas to receive long-acting reversible contraceptives, which are highly effective, expensive and require specialized training to insert.

In the years that immediately followed the cuts, more than 82 clinics closed or stopped providing family planning services, and those that remained served about half the patients they had before, according to researchers at the University of Texas at Austin’s Texas Policy Evaluation Project. Fewer lower-income women were able to receive family planning and reproductive health care, and those that did had less access to the most effective birth control methods, like intrauterine devices and implants, the researchers found.

Without insurance or the federal subsidy, the cost of long-acting reversible contraceptives like an intrauterine device or a matchstick-sized implant in the arm can cost more than $1,000.

That kind of expense is prohibitive for a patient like Marissa Villalpando, 22, who used to pay $200 to $300 out of pocket to get birth control from a nearby gynecologist. She’d been taking pills that were cheaper, even though they gave her side effects like sweats and cramps.

“I don’t have that kind of money,” said Villalpando, who began coming to Midway Family Planning about four years ago, while pregnant with her daughter.

When she stopped by the clinic on a Tuesday, with a stethoscope around her neck, she told the staff that she was studying nursing and said she might want to be a doctor.

“Well good for you!” Guinn said.

Villalpando was also “between houses,” she said — her small family had been kicked out of a family member’s home — and both her and her partner’s cars had broken down over the summer. She had borrowed a vehicle from a family member to drive to the clinic after class and was grateful Midway was open because other offices had been closing midday due to COVID-19, she said.

“Now would not be the time to get pregnant … This is something small, but at the same time, it could be so, so big. It could be another baby,” said Villalpando.

John Sommer, a licensed clinical social worker in Brownwood who counsels children and adults and works with the region’s probation departments, said it’s an understatement that poor women in the county are “underserved.”

They use the hospital for “everything,” even a terrible sore throat, because they lack insurance, and “there are virtually no places to be able to get help.” He typically refers poor patients he works with to AccelHealth, a federally qualified health center that also offers contraceptives and cancer screenings. Medical professionals tend to leave for bigger cities after a “stop-off” in Brownwood, he said.

In addition to specialized family planning clinics like Midway, local health departments, academic health centers, federally qualified health centers and other broad-service providers offer contraceptives and cancer screenings to low-income women, funded by the state or through the federal Title X program, said Stacey Pogue, a women’s health policy expert at the left-leaning Every Texan think tank. (Every Body Texas administers Title X funding in the state.)

The state programs are generally more limited — one excludes undocumented immigrants and younger teens seeking reproductive health services. But a challenge for women is just finding which clinics nearby participate in the programs, Pogue said — an exercise that often involves cross-referencing maps on different websites and calling the providers listed.

“There’s stretches of rural Texas that might be pretty underserved — where you’d have to go pretty far to get to a provider,” Pogue said, and it could be the same in certain pockets of urban and suburban areas.

Back at Midway, Parker herself recently went hunting for a women’s health provider. Two of her young patients had returned to college in San Angelo and were looking for a place to get their birth control shots. But “between here and there, no doctor, no clinic, nobody” in the state’s health program seemed to be available, Parker said.

Ultimately, Parker and a nurse met them at the clinic on a Sunday in October, more than a month after their shots were due.

Problems statewide

Doctors and hospitals across the state have struggled to survive the financial hit of limiting nonessential procedures and face-to-face contact that was recommended in the early months of the pandemic. Some doctors stopped seeing new patients and even hospitals preparing for the virus were forced to furlough or lay off staff employees during the spring.

Coupled with patients’ own financial challenges, the results spell trouble in some rural areas, where people have to travel long distances to see a nurse or doctor, or lack access to broadband, said Jane Bolin, deputy director of the Southwest Rural Health Research Center at Texas A&M University, and an associate dean at the college of nursing.

Texas has had the most rural hospital closures of any state in the last decade, according to one analysis, and some 30 counties don’t have a primary care doctor. The state has the highest rate of people uninsured of any nationwide, and one of the highest teen pregnancy rates.

“For rural individuals, they may go five years in between a simple clinical breast exam and it’s not because they intend to — it’s just, they have to choose: ‘Do I put milk on the table? Do I feed my family or do I go in and pay $300 per screening?’” Bolin said. “And then, if something is diagnosed as being suspicious … Well, then it may mean a trip into inner city Houston” for treatment and finding transportation and time off from work.

Parker has sometimes arranged for a government-funded van to transport her patients 80 miles to Abilene to get no-cost mammograms or other diagnostic screenings that require specialized equipment. If the patient can’t cover the $1.25 to $4 fare, the clinic will.

Women’s health providers in other parts of the state face challenges similar to Midway’s.

Consider the situation at Amarillo’s Haven Health, which regularly sees patients from Lubbock, Dalhart and Perryton, all a one- to two-hour drive away.

Located in a one-story beige building, Haven is the only family planning clinic in 41 counties and the area’s sole provider in Title X — a federal program offering reproductive health care to low-income people, according to chief executive officer Carolena Cogdill. Before a massive state budget cut in 2011, Cogdill said there were a half-dozen or so clinics spread throughout the Panhandle.

“It’s not like a metropolitan area where there might be four or five different clinics,” she said. “You kind of have to plan your day because it might take you two hours to get here, you’re here for an hour and then two hours to go home … If you have kids, you need to think about child care.”

The Amarillo clinic has seen more new patients as the local health department began referring STD cases to them, and the money the clinic receives from the state for family planning has been depleted faster than normal because of their rising numbers, she said.

“With COVID, particularly in Amarillo, a lot of people are employed by small businesses and small businesses were hurt,” she said. “We still have a lot of people who are unemployed and who are struggling to make ends meet, so Haven is the only place they can come to get assistance.”

It’s a similar story in the Corpus Christi area, where Martha Zuniga, executive director of a network of family planning clinics, has seen patients coming in with less income compared to before the pandemic. More are asking for long-acting reversible contraceptives.

Many of the general providers redirected their services to focus on the coronavirus, leaving patients wanting medical care without access to short-term appointments, Zuniga said. The clinics absorbed the overflow of patients coming from nearby health facilities and took on treatment of sexually transmitted diseases when the public health department limited its operations to handle the virus.

“Where do you think those patients went? They couldn’t pay a private provider,” she said. “They were asking us to refill their diabetes medications, to refill their hypertension medications they were getting” from other health centers or to remove long-acting reversible contraceptives they received from providers who curtailed in-clinic visits.

Elsewhere, along the Texas-Mexico border, Access Esperanza Clinics in Hidalgo County has seen a decrease in patients because the area was a coronavirus hot spot with rampant community spread. Between 30% and 40% of the population in the region are uninsured, living in poverty and don’t have access to reliable WiFi or computers, said Patricio Gonzales, the clinics’ chief executive officer.

“A lot of women are now losing their employment or their child care resources because of the pandemic,” he said in a September interview. “We’re expecting a lot of those women to start coming in as soon as things start to stabilize.”

Disclosure: Every Texan, Planned Parenthood, Texas A&M University and University of Texas at Austin have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune’s journalism. Find a complete list of them here.

This article was initially published at TexasTribune

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