For Amy Hagstrom Miller, providing high-quality reproductive care to women is a mission.
It’s tough enough to run a small business. Try being an abortion provider. In Texas.
Fourteen years ago, Amy Hagstrom Miller opened her first abortion clinic in Austin, with the goal of providing compassionate care to women seeking to end unwanted pregnancies. She purchased the practice from a retiring doctor, one of many who had set up an abortion practice in the 1970s following the landmark Roe v. Wade ruling.
Hagstrom Miller, now 50, sought to make examination rooms in her clinics “warm and comfortable,” naming each one after female trailblazers: Amelia Earhart, Georgia O’Keeffe, Margaret Cho. “I have a more holistic, feminist, woman-centered approach,” she says. “I’ve sort of become the next generation of abortion providers.”
As a small business owner in the abortion-care industry, she is not alone. The majority of abortion care in the U.S. is provided by independently owned clinics, not private doctors, hospitals or big health centers like Planned Parenthood, according to a July report by the Abortion Care Network, a nonprofit that supports abortion providers. But their numbers are dwindling: Since 2012, some 145 out of 510 abortion clinics have closed, a 28% reduction in just 5 years, according to the report.
It’s not due to lack of customer demand, although fewer women are having abortions. In 2014, the latest year for which there is data, there were about 926,000 abortions, compared with 1.06 million in 2011, according to the Guttmacher Institute, a research group that supports abortion rights. Instead, most attribute the clinic closures to anti-abortion regulations, particularly in politically “red” states.
In the last 6 years, states have passed 338 laws that put stiff restrictions on clinics, making abortion more difficult to access, says the Abortion Care Network. When clinics close, “patients are forced to travel farther, find overnight lodging, take additional time away from work (often unpaid), and find childcare,” says the Abortion Care Network report. In some cases, patients are unable to obtain reproductive care at all.
In 2013, Hagstrom Miller, founder of Whole Woman’s Health, was forced to shut or scale back several of her Texas locations because of a new state law, HB2 (famously filibustered by then-State Senator Wendy Davis). The law required that doctors have admitting privileges to a hospital within 30 miles, and that facilities “become ambulatory surgical centers, which is like a mini hospital — completely unnecessary for abortion services,” she says. The law immediately forced more than half of Texas’s abortion clinics to close, which Hagstrom Miller and other owners leveled was the legislation’s intent — not women’s safety, as proponents had claimed.
Hagstrom Miller became lead plaintiff in a lawsuit against Texas that ultimately made its way to the U.S. Supreme Court. “There was no question that we needed to bring a lawsuit and try to make it right,” says Hagstrom Miller, who was represented pro bono by the Center For Reproductive Rights. She estimates she still spent about $1 million fighting the law. “Our facilities got shut down and we still had rent and mortgages to pay,” she says.
In June 2016, the court ruled in favor of Whole Woman’s Health — the most significant ruling from the Supreme Court on abortion in two decades.
This past spring, Hagstrom Miller finally re-opened her flagship Austin location, writing an OpEd in the Dallas Morning News that the decision was “part of a bigger commitment to defend women’s access to abortion nationwide.” Anti-abortion restrictions are designed to shut down clinics and “shame and stigmatize the women who are having services,” she says. “One of my goals [in serving as plaintiff] was to raise the humanity of the abortion provider in the American public’s mind.”
The Business of Reproductive Care
The fact that most abortion clinics are small businesses is sometimes lost on the general public, even abortion-rights supporters. Hagstrom Miller considers herself a social entrepreneur, with more experience than most. “As a business person, I have quite a narrative,” she says. “I’ve had an angel investor, I’ve converted to shares, I’ve taken on a partner — I’ve done everything to get capital. And I learned it all as I was going.”
She grew up in Minnesota in a family business; her dad ran a custom-home-building company out of the house. While a student at Macalester College, she studied abroad in India. “It was one of the first times I really poked deeper into, what do women need to really be equal citizens in a society,” she says.
After graduating in 1989, she walked into a Planned Parenthood and asked for a job. “Clinics were being bombed,” she says. “This was a political moment in our time where you could really have meaningful work.”
While her first job at Planned Parenthood was answering phones, she eventually trained to be a counselor — and then learned how to manage a clinic. In 1995, she moved to New York and helped a group of doctors set up the Westside Women’s Medical Pavilion, which provides abortion services. “I learned a ton,” she says. “I picked the wallpaper, ordered all the instruments, hired all the staff, placed all the advertisements, really grew the practice from the ground up.”
In 2000, she was recruited to Austin, Texas, to help turn around a 1970s-era abortion clinic. “They needed the practice to be revitalized, to be turned around financially,” she says. Under her management, the bottom line quickly became much more robust, she says. At the same time, the Texas legislature began passing more restrictive laws. That’s when she realized that instead of protests, the anti-abortion movement was using “the power of the state to try to shut the clinics down,” she says. “From their perspective that’s actually much more effective.”
By 2003, Hagstrom Miller felt ready to own her own clinic — “especially in place like Texas,” where she felt women needed extra support. “I knew all the variables into making it successful,” she says. A wealthy college friend loaned her the money to buy the Austin clinic of a doctor who was retiring; she re-opened it as Whole Woman’s Health. Within 6 months, she bought a second clinic and merged the two, with her friend acting as an angel investor. “And then most of the clinics I bought from that point forward, I was able to do seller financing,” she says, where a doctor selling the clinic would lend her the money to buy it.
Over the years, she’s acquired 12 clinics in various parts of the country. Whole Women’s Health currently has four locations in Texas, and one each in Maryland, Minnesota and Illinois, with two more pending in additional states. She employs 140 staff members, plus an additional 25 independent contractors who are physicians.
“If you’re a traditional business person, if you’re interested in only making money, running an abortion clinic would be the last thing to do,” she says, especially in red states. “On that level, it’s kind of crazy.” Profit margins are thin — less than 3 percent, she says. And despite the Supreme Court win, there are still barriers to entry, from legislation restricting insurance coverage for abortions, to laws requiring that embryos are buried, regardless of a woman’s beliefs (Hagstrom Miller is currently fighting the latter in a new lawsuit).
But if you’re mission-driven, it’s an excellent enterprise, especially if you believe women “deserve access to high-quality care, she says. “The ability to control our fertility … is integral in our ability to realize our dreams and to have a future that we can plan for.”
Posted: September 28, 2017