Editor’s Note: This is part of our Good on the Ground series, profiling entrepreneurial women who are addressing social issues in innovative and inspiring ways.
It’s tough enough to run a small business. Try providing abortions 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.”
Amy Hagstrom Miller: The Abortion Provider
SOT Hi, Amy!
-Hi, how are you? Here I come.
Amy Almost 40% of American women will have an abortion at some point in their life. For most women abortion isn’t a struggle. For most women they’re relieved and they’re happy to, you know, step into the future of their life.
SOT Super good to see you!
-Good to see you!
Amy And for some women there’s a struggle that mainly comes from the outside, the shame and stigma that comes from sort of what people have told them they’re supposed to feel, or what people have, have told them the kind of woman that has an abortion.
TEXT Amy Hagstrom Miller – Founder + CEO – Whole Woman’s Health Clinics – Dallas, Texas, USA
SOT Hi, how are you?
-Good, how are you?
-Good. My name is Angel, I’m going to take you down to the lab.
Amy Facing an unplanned pregnancy and the ability to control our fertility is really integral, not only to our ability to exercise our full humanity as women but it, it is integral in our ability to realize our dreams and to have a future that we can plan for.
TEXT Amy was born and raised in Minnesota, the youngest of five children.
Amy I was born and raised in a really liberal, Christian tradition. The expectation was “excel at all the things you do,” so academic honor roll, I was also a swimmer and a cross-country skier.
TEXT Amy studied religion at Macalester College.
TEXT In 1986, as part of her degree, she spent a year in India and lived with a
Amy India was really formative for me. It was one of the first times I really poked deeper into, what do women need to really be equal citizens in a society?
TEXT After graduating in 1992, Amy married her college boyfriend Karl Miller.
TEXT That same year she walked into her local Planned Parenthood and asked for a job.
Amy In the early Nineties clinics were being bombed. Clinics were being blockaded. It was almost like a nexus of what, what was happening in our culture at that time. This was a political moment in our time where you could really have meaningful work.
TEXT At Planned Parenthood, Amy began doing office work and then trained to be a counselor.
Amy I was drawn to the direct services part of it, to sitting with a woman at a time when she looks at all of her values, and her hopes, and her dreams and tries to make a really big decision.
TEXT Over the next 2 years, Amy learned to manage a clinic.
TEXT When she was just 27, a group of doctors asked her to start the West Side
Woman’s Clinic in New York City.
Amy The abortion experience in New York was completely different than in
Minnesota. The procedure, of course, is exactly the same, but people’s experience, the culture, the values show up really differently in different parts of the country.
TEXT For 5 years Amy managed patient flow, finance, health insurance,
Medicaid and staffing.
Amy It was a great experience. But I felt that this sort of human rights,
injustice activist peace wasn’t really needed in New York and that women’s access to abortion care services should be the same whether they live in Indiana, Louisiana, Alabama, or Massachusetts.
TEXT Amy found a doctor in Austin, Texas, who wanted to sell his clinic and
TEXT A college friend loaned her the money to buy him out.
TEXT In 2003 Amy opened her first Whole Woman’s Health Clinic.
SOT You can relax your arm.
SOT Part of what we’ve done is really intentionally creating a physical space
that’s really comfortable and warm, and then I’ve named each of the rooms after different women throughout history. So it really sort of changes how you might feel.
TEXT Two years after opening her first clinic, it was profitable. Amy quickly
acquired two more.
Amy Most of the clinics I bought from that point forward I was able to do
seller financing. So the doctor would contact me and be interested in selling their practice, and then usually they thought it was worth a lot more than it is worth ’cause, you know, buying an abortion clinic in Texas, not really, you know, not that many people interested, right.
TEXT By 2013 Amy had five clinics in Texas.
TEXT That year the Texas legislature, in spite of huge protest, passed House
TEXT The bill imposed severe restrictions on the state’s 44 abortion clinics.
Amy HB2 required doctors who provide abortion services to have admitting
privileges in a hospital within 30 miles of the clinic. It required all abortion facilities to become ambulatory surgical centers, which is like a mini hospital; completely unnecessary for abortion services but here again, making that requirement basically trying to shut all the facilities down.
TEXT Amy and several other independent providers decided to sue the state of
Amy These laws needed to be challenged. The misinformation that they were
based on, erroneous, you know, health and safety kind of claims that they made were completely unsubstantiated. So there was no question that we needed to bring a lawsuit and try to make it right, but the odds were very much against us.
TEXT Amy became the lead plaintiff in a battle that went all the way to the
Amy It cost us well over $1,000,000. The lawsuit took at least three of our
highest-trained staff to prepare for, both in preparing all the documentation. Our facilities got shut down and we still had rent and mortgages to pay, we had staff to layoff, we had equipment leases we were still paying.
Question Did you ever think you might not make it through this time?
Amy Yes. Yes, multiple times. The money losses were really difficult
especially when I personalize it and I realize like, “Oh, there went the college fund for my kids, et cetera.”
TEXT In June 2016, after 3 years of litigation, the Supreme Court ruled in
favor of Whole Woman’s Health.
SOT Oh, man. I am beyond elated. Every day Whole Woman’s Health Clinics
serve women with respect and passion and dignity and compassion that they deserve. And today the Supreme Court did the same.
Amy Our victory in the Supreme Court has changed the game like
fundamentally. It’s changed the whole field way beyond Texas’ borders.
TEXT But during the tough legal battle, more than half of Texas’ clinics closed.
TEXT Amy now has three clinics in Texas as well as one in Maryland, Illinois
Amy I’ve learned a lot about medicine. I’ve learned a lot about business. I’ve
learned a lot about law. But all of that is at a byproduct of that central commitment that I have to sitting with a woman at a time of need and really advocating and supporting her to choose a course for her life.