Forced to Surrender

A New Orleans medical clinic had no choice but to close after a withering, years-long attack by the government designed to stop abortions.

Maria Couevas is anything but a quitter. The facts of this story will prove that out. But the most brutal fact of all is that the state of Louisiana, through the concerted efforts of powerful government agencies united by an ideological agenda, used any regulation or rule it could to stop Maria and Midtown Medical, the reproductive health facility that she owned and managed, from offering constitutionally protected abortion services to women in New Orleans.

In the end, Maria and the clinic's commitment to providing access to safe services became their downfall. And Louisiana women are that much closer to the grim reality faced by women in Mississippi and North Dakota, each with only one clinic.

Maria started working at an OB-GYN office more than 20 years ago. The doctor there offered a variety of reproductive health services, including contraception, prenatal care, and wellness services. Abortions were a small piece. Over time, she watched the Board of Medical Examiners harass the doctor, subjecting him to reviews by other physicians who weren't trained OB-GYNs. Those reviews lead to unfounded accusations that he'd performed inappropriate procedures. In 2006, the government took his medical license.

Soon after, Maria started Midtown Medical, a group of OB-GYN doctors, each with private practices. State law required the group to get an abortion license since they performed more than five abortions per month. Midtown soon became a cornerstone of a community that sorely needed access to health care.

"Our policy was that we would never turn a patient away," says Maria. "No money, no insurance, it didn't matter. We never turned someone away."

By 2011, Midtown was seeing more than 12,000 patients. About 700 came for abortions. The rest counted on Midtown to deliver their babies, or for pap smears, numerous forms of birth control, and for their primary care.

But maybe the most important thing to know about Midtown is that it served people in need. About 95 percent of the clinic's revenue came from Medicaid patients—none of which went to the provision of abortion, in compliance with federal and state law.

Maria's commitment to serving lower-income women opened an avenue for the government to launch its attack on Midtown. Louisiana's Department of Health and Hospitals conducted seven Medicaid audits in just five years. "They really came after me in 2011," says Maria. "Bam bam bam, one right after the other."

Each time, investigators found next to nothing. Over a five-year period, less than $3,000 in errors were found—the majority related to computer glitches during a system update. Midtown's error rate of .07 percent is a mere fraction of the 2011 national Medicaid error rate of 8.1 percent.

In May 2012, though, a Medicaid surveillance unit took issue with $22,000 worth of IUDs that Midtown purchased. The Department of Health and Hospitals' Medicaid Division claimed that Midtown did not submit the required documentation to prove that the IUDs were approved by the Food and Drug Administration. Maria says that there is no Medicaid regulation that requires this type of documentation, and that the Medicaid Division never told Midtown that such information should be submitted. Instead, the health department revoked Midtown's ability to bill Medicaid, something that rarely happens, according to Maria's attorney.

Despite the nearly complete loss of revenue, Midtown forged ahead and continued seeing patients as it appealed the decision in court. Maria and Midtown's primary doctor stopped taking a salary in May 2012. According to Maria, Medicaid owes them far north of $100,000 for services rendered.

Even as the Medicaid Division choked off most of the clinic's revenue, another division within the health department—the Health Standards Department—revoked Midtown's abortion license for a handful of unfounded allegations.

The final straw, though, came when the clinic's medical director died unexpectedly in December. Maria scrambled to replace him, reaching out to the doctors she knew who understood the importance of women having access to reproductive health care. One after another, the doctors refused to take on the role. Each knew, based on the experience of other physicians, that with such an appointment comes the withering scrutiny and consequent investigations by the Board of Medical Examiners.

Reality set in, and Maria decided to stop the search. "I've watched them take down doctor after doctor," says Maria. "I can probably count ten of them off the top of my head. I would've fought it tooth and nail, but I don't want to put these doctors livelihoods in jeopardy. I can't put anybody's license on the line like that."

So the state of Louisiana won. They forced Maria to close her doors on January 3, 2013. "I think they've thought this out," she says, explaining that the reason they went after Midtown with such vehemence was because Maria refused to lay down. "We fight back against everything," she says. "I didn't ever want to be known as a multiple offender," knowing that if the clinic didn't push back against unfounded accusations about improper Medicaid billing, they'd be seen as providing low-quality care. Maria won almost all of those fights. "This is basic retaliation."

Midtown won't be the last clinic to close in Louisiana. A 2010 Louisiana law gives health officials broad authority to revoke abortion licenses immediately in the wake of any alleged violation of a federal or state regulation, no matter how minor or legitimate—from typos on forms to wrongly placed garbage cans. Her former colleagues, who own and manage the remaining five abortion facilities across the state, are left to shoulder the pressure and intense surveillance from the government. "I talked to all of them when I closed down, and it's like, 'How many of us are left?' It's a feeling of doom."

Maria and her staff aren't the only people who have suffered a loss. Twelve thousand women and adolescents need new doctors, prescriptions for contraception, pregnancy tests, and, most importantly, a place to get health services when they need them most. "It's not easy for Medicaid patients to get care anyway," says Maria. "Every day, I have patients calling, literally crying. They say, 'I don't even know where to go.' We were taking care of patients we've delivered. It makes me want to cry."

Maria's future is unclear. "I'm tired," she says. "We're all tired." But she's not yet out of the fight. She wants her Medicaid license back. And with it her reputation.

"I have to make sure we continue because I don't want to fade off and let the government continue what they're doing. I don't think it's right," she says.

And yet the assault will almost certainly continue. Louisiana women could one day face the same stark situation that threatens Mississippi and North Dakota—having to cross state borders and incur significant costs to secure constitutionally protected health care.

Is your state next? It might have 12 clinics today, or maybe eight. But how long until it's the next Louisiana, and then the next Mississippi?

After all the audits, all the investigations and the hostile inquiries, one thought about the government's hunt for her clinic still haunts Maria. "Not once did anyone care about the patients."