Pink flags swayed on the Pentacrest last week, inscribed with students’ stories about having control over their reproductive options, including birth control and sex education, and how that has affected their lives.

“Access to birth control matters because …” one prompt read. Written in a tight scrawl were the words “I want to continue my education.”

Iowa City remains a health-care engine, with no shortage of low-cost family-planning options for students — including Student Health & Wellness, a remaining Planned Parenthood, and the Emma Goldman Clinic, among others.

When students return home, however, their options may be limited.

After four Planned Parenthood Clinics closed across the state eight months ago, early government data obtained in record requests in February provide a rough sketch of the effect on teenagers and low- to moderate-income women after the state Legislature’s decision to divert funds from family-planning clinics that also provide abortions. That law went into effect in July 2017.

Last legislative session

In May 2017, state lawmakers turned down $3 million in federal Medicaid funds and instead created a $3.3 million state-funded family-planning program as it denied public funds to providers that offer abortions, including Planned Parenthood, University of Iowa Hospitals and Clinics, and Unitypoint Health Systems.

Previously, tax dollars did not go directly to abortion services, although proponents of the switch said public funds indirectly supported abortions by allowing the clinics to remain open.

The federal waiver program, which enrolled 12,219 people in December 2016, reimburses family-planning providers for nonabortion services such as pregnancy testing, STD/STI testing, and contraceptives for moderate-income Iowans who qualified for the program. The legislative decision did not change what the program covered, just excluded clinics that offered abortions.

In May 2017, Planned Parenthood of the Heartland announced it would close four of its Iowa clinics as a result of losing $2 million in funds from the decision. The clinics served approximately 14,600 people in the last three years, Planned Parenthood Heartland CEO Susan de Baca said. Clinics in Bettendorf, Sioux City, Burlington, and Keokuk shut their doors, leaving eight open in Iowa, including one in Iowa City.

What early data show: It’s difficult to measure

At the halfway point of the fiscal year, just 6 percent of the designated Family Planning Program budget had been given in claims, according to a records request.

From July 1 to Dec. 31, of a $3 million budget, $180,690.95 had been spent for family-planning services.

“First of all, there’s significantly less money being spent — I don’t see the other providers getting increased funds and reimbursements, so I don’t see them picking up that slack,” said Jodi Tomlonovic, the executive director of the Family Planning Council of Iowa.

The requests were originally filed by the Associated Press and the Cedar Rapids Gazette. The data were collected by the Department of Human Services and obtained by The Daily Iowan.

Human Services Public Information Officer,Matt Highland strongly cautioned against drawing conclusions from the incomplete data in an email to the DI, because providers have a full year after providing the service to submit claims.

The data also showed a dip in number of enrollees and providers in the program. There were 6,542 enrollees in December, which shows about a 46 percent drop from 12,219 enrollees in December 2016, and the number of providers dropped by a few hundred.

However, the number of enrollees in the program has been on a steady decline since 2013 as more people began looking elsewhere for coverage, because the limited family-planning program didn’t meet the requirements for insurance coverage mandated by the Affordable Care Act.

However, the drop in enrollees was the largest since 2014, after the Affordable Care Act was introduced.

Maggie DeWitte of Iowans For Life said she thought the data were too preliminary to show the true effect of the program.

“I think we need to take a step back here and realize that this is not full data that we’re talking about …” DeWitte said. “I think we’re sort of jumping the gun on this, and we need to take a step back and get more data and information.”

Tomlonovic of the Iowa Family Planning Council, which distributes federal funds for Iowa clinics, disagreed.

“When Iowa first made the switch, I thought that we were going to see far fewer people, that there was going to be a much bigger decrease in access for people around the state, and that’s what we feel like this first report has shown,” Tomlonovic said.

Iowa clinics weigh in

Brandi Steck, Title X program manager and HIV program manager of Siouxland Community Health Center, said her clinic just started accepting former Planned Parenthood patients last week after the clinic added family-planning staff and services funded by a federal grant program, Title X, targeted to help low-income individuals receive reproductive care.

That’s left a gap in family-planning services since June in western Iowa when one of the only providers of low-income reproductive health, Planned Parenthood, closed.

“I think unfortunately [former Planned Parenthood patients] didn’t go anywhere because they didn’t have anywhere to go,” Steck said. “Now we’re getting them in, but between June and February, I don’t think they were going anywhere.”

The first day offering expanded services, a woman who formerly went to Planned Parenthood in Sioux City came in to the clinic with a lump in her breast.

“She said that she noticed it a couple months ago, but she didn’t know where to go or what to do about it,” Steck said. “That was our first day. On our second day, we found two new cases of syphilis, so right there shows that it’s a necessary service, it’s a public-health issue if people with syphilis are going without being treated.”

Around 60 miles east of Iowa City, in the Quad Cities, CEO of Community Health Care Inc. Tom Bowman said his clinics added midwives to prepare for an anticipated surge in patients from Planned Parenthood’s closure in Bettendorf. However, he said, his six clinics haven’t seen an increase in the number of patients.

“It’s my hope that [former Planned Parenthood patients] were able to transfer their care and there was enough capacity in other practices,” Bowman said. “But I don’t have any way to verify that. The worst-case scenario would be if a lot of Planned Parenthood patients have just decided to go without care right now.”

The clinic is a federally qualified health center, the type that proponents of defunding Planned Parenthood said would be able to fill the gaps in coverage.

Another 40 miles northeast, in Clinton, Women’s Health Services head Joanne Hermiston said she’s concerned about a general trend of loss of government funds. Approximately 80 percent of her clinic’s patients are below 100 percent of the federal poverty level and often on some kind of public aid. In 2017, she said, her clinic experienced a spike in STD and HIV testing.

“Demand is up, yet over the past few years we’ve seen about a 35 percent decrease in funding from the state and federal level,” Hermiston said. “So it’s kind of hard to see how you’re going to continue into the future, but we persist.”

According to a February report from the Iowa Department of Public Health, cases of gonorrhea have increased 145 percent since 2013. For Hermiston, it underscored the need for continued public funds for family-planning programs in as many locations as possible, especially for Iowans struggling to remain above the poverty line.

“There are people just living on the edge, they make enough money to not qualify for some programs but not enough money to cover their expenses, and they’re one car breakdown away from living in poverty … and these programs just take away the little worry they might have,” Hermiston said.

According to a Des Moines Register poll conducted in January, 71 percent of Iowans support restoring funds to Planned Parenthood for nonabortion-related services, and 25 percent oppose it.

In Iowa City, neither the Emma Goldman Clinic or the UI Hospitals and Clinics have said they were particularly affected by the loss of funds, nor were they seeing an increase in the number of patients.

“We have not had clients making appointments mention it, which could mean the people it has affected are paying out of pocket, just choosing to go elsewhere for [nonabortion] services, or not getting preventative care,” Emma Goldman Co-Director Francine Thompson said.

For the UIHC, spokesman Tom Moore said it also has not felt the effect.

“The previous Medicaid Family Planning Waiver was not a significant payer, meaning that people enrolled in the program were largely receiving their family-planning care elsewhere,” he said.

There are still federal funds for family planning, but it’s on the ropes, too

Funds for Title X run out as early as March, but the national office has delayed announcing how grantees can renew funding.

“We’re nervous. We’ve been told over the last few weeks that something is being worked on to help us get through this time. But we haven’t seen anything yet,” Tomlonovic said.

Funds will run out in June for Iowa’s two Title X grantees — the other being the Iowa Department of Public Health, though some other states’ funds run out March 31. Title X funds are granted to clinics that provide services on a sliding fee scale based on the patient’s income. The dollars help pay for staff, contraceptives, and other nonabortion services. Unlike Iowa’s waiver funds, Title X funds can be granted to clinics that provide abortions, such as Planned Parenthood.

If the grants aren’t renewed, Iowa would lose $4 million in family planning grants Tomlonovic said.

The process generally takes four to five months, fueling concern that if the U.S. Department of Health and Human Services doesn’t come out with instructions soon for the lengthy application process, programs could experience gaps in funding.

“Normally you know — when your project period ends what’s going to happen and will there be funding, but because of this delay, it’s causing a real problem about knowing what funding will be available,” Tomlonovic said.

She said the department has delayed the announcement since last year.

“Well, first, it was October, then, it was November, then — I mean, that’s been kind of a problem,” Tomlonovic said.

In an email to Title X providers, Valerie Huber, the assistant secretary for the department that oversees the national office for the Title X program, told grantees across the country not to worry.

“The Title X program is important to this administration,” she wrote in an email. “We are committed to the women and men who depend upon Title X services and efforts are already underway to ensure that there will be no gaps in service while the funding announcement is finalized.”

List of participating members

For women looking for alternatives to Planned Parenthood the Department of Human Services provides a list online of locations where Iowans can access family-planning services that accept the state-backed limited insurance plan. The database lists 1,355 providers. Many are duplicate addresses, don’t prescribe birth control, or are independent labs that don’t see patients.

Other state efforts to limit abortion

The Iowa state Senate has introduced a bill that would charge doctors who perform abortions after a fetal heartbeat is detected with a Class D felony, which could garner up to five years in prison.

RELATED: University of Iowa OB/GYNs, Board of Regents warn Legislature against Heartbeat bill

The state Board of Regents and American College of Obstetricians and Gynecologists have opposed the measure, noting that their OB/GYN residencies could lose accreditation if they cannot offer abortion training.