Q&A: How a Community Clinic is Overcoming a Political System that Left Behind Patients in Need

“If I have learned anything from five years of running a clinic, it's that for-profit medicine is killing people.”

Whoever said you should never meet your heroes has never talked with Robin Marty. I first knew of Robin through her years of reporting on abortion and reproductive justice, including her books, most recently The New Handbook for Post-Roe America.

In 2021, Robin moved from Minnesota to Alabama to direct the West Alabama Women’s Center, which at the time provided abortion along with other kinds of medical care. In 2022, when the Supreme Court issued its Dobbs decision that overturned Roe, abortion became illegal in Alabama. Since then, the center has carried on providing contraception, prenatal care, postpartum care, gender affirming healthcare, STI testing, treatment, and prevention. Their work is urgently needed. Alabama has abysmal maternal health outcomes. According to a recent study, more people die after giving birth in Alabama than in any other state.

I talked with Robin about how political corruption limits low-income Alabamans’ access to medical care–especially related to pregnancy– and what she and her community are doing about it.

Meaghan Winter: How do you see political corruption affecting West Alabama?

Robin Marty: We don't really have two political parties in Alabama. We have the GOP, and they run everything. Essentially, we have a machine: Republicans decide on their own who's going to take each spot as we head into the next election. Everybody who wants to be a part of the Republican Party knows you back off once somebody is declared for a certain seat. Voter suppression continues to be a problem, and in a lot of cases, we don't have Democrats who even run for office.

The way that Alabama works is essentially still a post-Reconstruction era system where you have monopolies, like Alabama Power or Alabama Blue Cross Blue Shield, and then those monopolies get to pick how much the rates are going to be.

And then here in Tuscaloosa, we have this enormous university that is responsible for most of the wealth that comes into the city, and because of that, the city primarily caters only to that entity. Near the university are all the bars, the restaurants, the good grocery stores. And then the rest of Tuscaloosa is pretty much abject poverty. And then we have West Alabama, where there is sewage that's still running through the streets. Everything’s divided by class lines, by race, by who the state thinks they have to cater to.

Meaghan: How does Alabama’s political corruption affect your patients?

Robin: Our typical patient is a Black woman, usually either uninsured or on Medicaid, usually below at or below the poverty line. In Alabama, if you are a single person, you do not qualify for Medicaid unless you make something like less than $5,000 a year. What that means is that essentially, no one is on Medicaid if they are able-bodied.

The income level goes up the moment you become pregnant, so more people are eligible when they’re pregnant. However, you can't actually apply for Medicaid until you have had a doctor confirm your pregnancy. But no doctor will see you because you don't have insurance and they can't guarantee they’ll get reimbursed. What that meant for our patients was going to the county health department for a pregnancy confirmation, applying for Medicaid, and waiting for months for prenatal care.

In Alabama, 25% of all people who become pregnant do not get any prenatal care in the first trimester. That rate goes up to 34% when you are Black, and it goes up to 54% if you are Hispanic. So, these are all people who are getting inadequate and late prenatal care, and they likely didn’t have good preventative care to begin with. So, after Dobbs, our decision was that for as long as we could manage to stay open, we were going to make sure that we had same-day appointments so people could come in and get their [pregnancy] confirmation done.

I would say 75% of our patients who are pregnant are Medicaid patients, and we don’t get reimbursed for seeing them. We see them for free.

We’re not an approved Medicaid pregnancy contractor because we would need a written agreement from a delivering doctor saying they will accept our patients. Because we used to be an abortion provider, no one will do it. Even though our clinic’s name is changed, even though we’re not providing abortions anymore, we can’t find anyone to do it. That ends up meaning that we can’t get reimbursed for treating pregnant patients. It’s ridiculously frustrating. We're just making sure patients get early and consistent care.

So, about 15% of our yearly annual income comes from insurance reimbursement or patient out-of-pocket payments, and the other 85% of it is all donations and grants. The amazing thing is that donations are primarily small-dollar donations. Most of our donors give less than $50 and we raise about $300,000 a year just through these $50 or less donations. It's truly a community. It's a community clinic, and it's supported by a community of donors throughout the country that uplifts it.

Meaghan: What are you able to do for your patients?

Robin: We’re able to address high blood pressure, check for diabetes, all of these things that people would normally have to wait months to access. We make sure patients are getting good early care, and that they have better birth outcomes. We also chose to start providing a free doula who can accompany them to the hospital and provide continuity of care. Honestly, it’s been really successful.

We brought in a certified nurse midwife, and we have patients coming in the door without appointments asking if they can see her because she is the only Black provider in the city of Tuscaloosa.

What is it like to have a healthcare system that doesn't see you as a person? Half of the residents of the of the city can't find a provider that looks like them, that they feel actually listens to them, understands their experience, understands that, hey, if somebody has a headache, then maybe you need to check their blood pressure, because they might be getting preeclampsia rather than saying, “Oh, well, why don't you take some Tylenol and go home and rest. Because I'm sure it's not as bad as you think.” Those are real experiences that we have to address, and not just in the South, but throughout the country as well.

We’re launching a new program to do postpartum doula care for more months following birth. We’ve seen data that one-third of all postpartum maternal deaths occur after that initial postpartum period when people are usually being monitored. So, we need to keep on top of that and provide more care in those later months.

If I have learned anything from five years of running a clinic, it's that for-profit medicine is killing people. And honestly, it's not a system that's sustainable anymore. What I envision happening is that it’s going to go one of two ways. Either we’re going to somehow manage to wrangle back the complete catastrophe that is our healthcare system and turn it into Medicaid for All, or what's more likely, based on what we're seeing right now with Trump, is that we are going to have a healthcare system that is primarily out of reach for most Americans, except for the most elite.

Meaghan: With so many terrible things happening, how are you coping?

Robin: I love our staff. Our doula program has turned into something amazing. The same with our midwives. This is the first time that some of our patients have felt seen and heard, and they tell us that. It’s the first time that some of them feel like they are a part of a community that cares about them.

We do free rummage sales. We have a food pantry. We sometimes will get hotel rooms for unhoused people who need to be off the street for a bit in order to recover from whatever medical issue they're dealing with. These are all things we do because we know that when you have a healthy community, everybody prospers.