“Where else in medicine can you, mul­ti­ple times a day, change a woman’s life in five min­utes?”


Bloomberg Businessweek (Asia) - - CONTENTS - BY MEAGHAN WIN­TER

Hop­ing to pub­li­cize her new non­profit, last fall Julie Burkhart called her lo­cal NPR af­fil­i­ate, KMUW in Wi­chita, about buy­ing a day of spon­sor­ship for $480. Sta­tion man­ager De­bra Fraser de­cided im­me­di­ately that KMUW wouldn’t al­low it. “I didn’t want to up­set the ap­ple cart,” Fraser says.

The re­sponse wasn’t new to Burkhart. In April 2013 she had re­opened and re­named Women’s Health Care Ser­vices, where her for­mer em­ployer and men­tor, Dr. Ge­orge Tiller, pro­vided abor­tions from the 1970s un­til 2009, when he was shot in the head and killed while ush­er­ing at his church. To­day, South Wind Women’s Cen­ter of­fers abor­tion and OB-GYN ser­vices as well as trans­gen­der care such as hor­mone ther­apy. Burkhart hopes to in­stall a birthing cen­ter. In the base­ment, Trust Women, the cen­ter’s um­brella non­profit, runs a political ac­tion com­mit­tee, con­tin­u­ing the ad­vo­cacy Tiller be­gan in the 1980s.

“We are only ask­ing to be treated like any other busi­ness that pro­vides health care,” Burkhart wrote in a let­ter to KMUW ap­peal­ing the sta­tion’s re­jec­tion. She says a man in the de­vel­op­ment of­fice told her that if the sta­tion ac­cepted South Wind’s spon­sor­ship, it would have to ac­cept spon­sor­ship from anti-abor­tion or­ga­ni­za­tions, too. “The fundraiser in me thought, What’s the prob­lem with that?” Burkhart says with a laugh. But she was taken aback, she re­calls, when he asked if she thought KMUW should also take do­na­tions from the Ku Klux Klan. About that, Fraser says: “I cer­tainly would hope that no one on my staff would say that. That doesn’t rep­re­sent what I said to Julie.”

Burkhart and Fraser met for lunch. Fraser had pre­vi­ously worked at a Texas sta­tion where lis­ten­ers fre­quently called to com­plain about Planned Par­ent­hood’s spon­sor­ship. As a news or­ga­ni­za­tion re­liant on lis­tener sup­port, KMUW couldn’t af­ford to cre­ate the per­cep­tion that it was “tak­ing a stand” on abor­tion, Fraser says. “If I were you,” she re­mem­bers telling Burkhart, “I’d be re­ally up­set about this. But I can’t help you.”

The stigma around abor­tion pre­vents Burkhart’s non­profit from per­form­ing many of the ev­ery­day trans­ac­tions es­sen­tial to busi­nesses. She and other clinic own­ers have had trou­ble se­cur­ing mort­gages, med­i­cal in­sur­ance, con­trac­tors, and some­one will­ing to de­liver Band-Aids and bot­tles of wa­ter. Es­pe­cially in ru­ral and con­ser­va­tive re­gions, a wide range of com­pa­nies and or­ga­ni­za­tions de­cline to work with abor­tion providers, ei­ther for rea­sons of per­sonal con­science or be­cause of fears that be­ing as­so­ci­ated with abor­tion will cost them busi­ness.

In re­cent years states have en­acted hun­dreds of laws de­signed by ac­tivists to make it more dif­fi­cult—and more ex­pen­sive—to per­form abor­tions. Twenty-two states re­quire abor­tion clin­ics to fol­low codes com­pa­ra­ble to those of am­bu­la­tory sur­gi­cal cen­ters; at least 11 states spec­ify the width of clinic rooms or hall­ways. Many clin­ics strug­gled to stay in the black well be­fore leg­is­la­tion re­quired them to re­model their cor­ri­dors.

A com­mon al­le­ga­tion by anti-abor­tion ac­tivists is that the doc­tors pro­vid­ing such ser­vices are in it for the money. “Their fo­cus is where the dol­lar is. It’s not pro­tect­ing women,” says Melissa Con­way, a spokes­woman for Texas Right to Life. “Es­pe­cially within the last few years, the cost of abor­tion ser­vices is in­creas­ing, and so it’s a very prof­itable busi­ness.” For many anti-abor­tion ad­vo­cates, that stand­alone clin­ics pro­vide most abor­tions is proof that “abor­tion­ists” are seedy char­ac­ters who aim “to garner fi­nan­cial gain on the backs of women,” as Con­way puts it. Texas Right to Life and its par­ent or­ga­ni­za­tion de­clined mul­ti­ple re­quests for ev­i­dence that run­ning an abor­tion clinic is lu­cra­tive.

The num­bers sug­gest the op­po­site. The av­er­age amount paid for an abor­tion na­tion­wide—about $450 for the most com­mon pro­ce­dures—has been rel­a­tively stag­nant for decades, de­spite in­fla­tion in other ar­eas of medicine and higher costs. In the 1970s anti-abor­tion at­tor­neys formed a decades­long plan to craft and lobby for state reg­u­la­tions that would grad­u­ally strip away physicians’ abil­ity to pro­vide the pro­ce­dure. Much of the leg­is­la­tion makes it more ex­pen­sive for clin­ics to op­er­ate, and the strat­egy has proved ef­fec­tive. Since 2011 at least 162 abor­tion providers have closed or stopped per­form­ing abor­tions, and 21 clin­ics have opened. That rep­re­sents the swiftest an­nual de­cline in the num­ber of abor­tion providers ever, ac­cord­ing to Bloomberg News. Burkhart is work­ing to start an­other clinic, in Ok­la­homa City, which she es­ti­mates will cost $1 mil­lion. No one has opened an abor­tion clinic in Ok­la­homa since 1974.

In 1976, Congress passed the Hyde Amend­ment re­strict­ing the use of fed­eral funds for abor­tion, which Amer­i­cans United for Life helped de­fend be­fore the Supreme Court in 1980. In 33 states, Med­i­caid can’t be used to cover the pro­ce­dure in most cir­cum­stances. Re­cent polling finds that al­most half of women who ob­tain abor­tions live below the fed­eral poverty line. Mean­while, 10 states, in­clud­ing Kansas and Ok­la­homa, ban all in­sur­ance plans—and 25 states re­strict govern­ment mar­ket­place plans—from cov­er­ing abor­tion ex­cept in rare cir­cum­stances. With a large share of women, in­clud­ing the poor­est pa­tients, pay­ing out of pocket, many abor­tion providers keep their prices low. “What you’re do­ing is—as much as you can—not pric­ing peo­ple out of get­ting this ser­vice,” says David Burkons, a physi­cian who opened a clinic in Ohio last year.

Clinic di­rec­tors say the political cli­mate has made it al­most im­pos­si­ble to open clin­ics. “You’d think, This is crazy,” says Amy Hagstrom Miller, founder and chief ex­ec­u­tive of­fi­cer of Whole Woman’s Health, which has ac­quired or opened clin­ics in five states since 2003. She’s the plain­tiff in the com­ing Supreme Court case over abor­tion laws that have shut­tered two of her five Texas lo­ca­tions. Ar­gu­ments be­gin on March 2. The ex­tra costs she and other providers face are at the heart of the case: The de­ci­sion will largely come down to whether the jus­tices think the laws have made it too ex­pen­sive for clin­ics to op­er­ate—and to what ex­tent that bur­dens pa­tients. Says Hagstrom Miller: “This is prob­a­bly the most dif­fi­cult busi­ness you could ever run.”

South Wind is the only abor­tion clinic for at least 150 miles in any di­rec­tion. The two other abor­tion providers in Kansas are a Planned Par­ent­hood af­fil­i­ate and a pri­vate prac­tice in Over­land Park, al­most 200 miles away. Be­cause there are so few places to get an abor­tion in the re­gion, pa­tients of­ten come from Ok­la­homa,

Mis­souri, and Texas. Ev­ery week, Burkhart flies in a physi­cian will­ing to per­form se­cond-trimester abor­tions. South Wind spends about $20,000 on air­fare an­nu­ally, and some­times pa­tient and doc­tor travel across state lines to meet at South Wind.

Set on a ser­vice road in a work­ing-class neigh­bor­hood, the clinic is squat, win­dow­less, and sur­rounded by a tall cedar fence “like a bunker,” as one staff mem­ber says. Af­ter a makeover by a donor, the wait­ing room looks like an up­scale ther­a­pist’s of­fice. Neu­tral-toned chairs face a paint­ing of irises. The lights are dimmed. The sooth­ing at­mos­phere is meant to coun­ter­act ev­ery­thing pa­tients pass through to get there.

At the mouth of the park­ing lot, Kansas Coali­tion for Life pro­test­ers record each vis­i­tor’s li­cense plate num­ber and time of en­try and track which car be­longs to each staff mem­ber. On a morn­ing in Oc­to­ber, they wait be­side a ban­ner that says “Ev­ery abor­tion is a cruel and bar­baric act of vi­o­lence” and shows a mu­ti­lated, un­clothed man in a Christ­like pose. Nearby is a trailer cov­ered with a gi­ant pho­to­graph of a fe­tus. Af­ter an armed se­cu­rity guard opens the locked door, he in­structs vis­i­tors to empty their purses and walk through a metal de­tec­tor. Burkhart es­ti­mates South Wind spends a min­i­mum of $45,000 on se­cu­rity each year.

In her of­fice, Burkhart gets off the phone with her at­tor­ney and makes an­other pot of coffee. She’s tall and makes mat­ter-of-fact state­ments in a flat tim­bre. Raised by a fem­i­nist mother (“lis­ten­ing to Free to Be … You and Me”), Burkhart, 49, first in­terned at an abor­tion clinic as a col­lege stu­dent. A fam­ily tragedy in­ter­rupted her plans to go to med­i­cal school, so she’s di­vided her ca­reer be­tween re­pro­duc­tive-rights work and other political ad­vo­cacy. She ran Tiller’s PAC for seven years.

South Wind is ex­pand­ing to Ok­la­homa be­cause the doc­tor at one of the two re­main­ing abor­tion clin­ics in the state is old enough to re­tire. Since states such as Kansas and Ok­la­homa pro­hibit pub­licly funded en­ti­ties from per­form­ing most abor­tions, lo­cal hospi­tals can’t train the next gen­er­a­tion to re­place ag­ing doc­tors. Na­tion­wide, med­i­cal schools don’t of­fer abor­tion train­ing. All OB-GYN res­i­den­cies are sup­posed to of­fer ac­cess to abor­tion train­ing, but a 2013 sur­vey pub­lished in the jour­nal Con­tra­cep­tion found that not all do.

OB-GYNs who do re­ceive train­ing rarely end up of­fer­ing abor­tions once they’re in prac­tice, of­ten be­cause their work­places don’t al­low it. In the U.S., 9 of 10 abor­tions are first­trimester pro­ce­dures that are med­i­cally sim­ple enough to be done in a doc­tor’s of­fice at lit­tle ex­pense. Across the coun­try, though, anti-abor­tion groups have protested and led boy­cotts against OB-GYNs who of­fer abor­tions; even when their doc­tors are pro-abor­tion rights, gyne­col­ogy prac­tices usu­ally de­cide against of­fer­ing the pro­ce­dure to avoid jeop­ar­diz­ing their busi­ness. And hospi­tals are also risk-averse: They per­form just 4 per­cent of the coun­try’s abor­tions. Many are pro­hib­ited by man­dates from the religious in­sti­tu­tions that run them or lo­cal gov­ern­ments. Oth­ers have lit­tle in­cen­tive to wade into di­vi­sive pol­i­tics. When in­sur­ance does re­im­burse for abor­tion, the rates are usu­ally low, says Lori Freed­man, au­thor of the


book Will­ing and Un­able: Doc­tors’ Con­straints in Abor­tion Care.

As a re­sult, clin­ics per­form 94 per­cent of abor­tions in the U.S. Planned Par­ent­hood is the sin­gle largest provider, but the ma­jor­ity of clin­ics, like South Wind, are in­de­pen­dent non­prof­its or small busi­nesses. To func­tion, they must con­tend with stan­dards that vary from state to state. Ad­vo­cacy or­ga­ni­za­tions in­clud­ing Amer­i­cans United for Life and Na­tional Right to Life have spent 40 years draft­ing and lob­by­ing for rules that make op­er­at­ing abor­tion clin­ics highly dif­fi­cult, such as the re­quire­ment that the clin­ics meet sur­gi­cal cen­ter stan­dards.

Am­bu­la­tory surgery cen­ters, or ASCs, are ex­pen­sive to build and main­tain. Their guide­lines are writ­ten for pro­ce­dures that re­quire op­er­at­ing rooms, so spe­cial­ists must be hired to set up heat­ing, ven­ti­la­tion, air con­di­tion­ing, and elec­tri­cal sys­tems that are more com­pli­cated than those in clin­ics. It’s the dif­fer­ence be­tween buy­ing a Fer­rari and a Volvo, ac­cord­ing to one ar­chi­tect who de­signs ASCs but doesn’t want to be named be­cause some of his clients are op­posed to abor­tion. The surgery cen­ters are re­quired to have a sep­a­rate source of elec­tric­ity in case of an out­age, and gen­er­a­tors can cost $50,000 apiece. In Ok­la­homa, where la­bor and ma­te­ri­als are rel­a­tively cheap, build­ing a clinic would cost about $175 per square foot; an ASC would run about $258. The ar­chi­tect says that on av­er­age, a sin­gle 300-square-foot op­er­at­ing room costs about $1 mil­lion, land ex­cluded. Equip­ment gen­er­ally costs an ad­di­tional $500,000 per OR.

Ok­la­homa has no ASC re­quire­ment. But in July, Burkhart sub­mit­ted an ap­pli­ca­tion to the state to open one, be­cause she wanted to pro­vide abor­tions up to the le­gal limit of 24 weeks of preg­nancy. The lot and build­ing—a for­mer op­tom­e­try prac­tice— cost $300,000. Ren­o­va­tions re­quired an ad­di­tional $550,000. Burkhart’s ar­chi­tect (not the one who com­pared surgery cen­ters to Fer­raris) was ready to start de­mo­li­tion but was stalled wait­ing for a li­cense from the state.

In late Au­gust, Burkhart fi­nally heard back. The Ok­la­homa State Depart­ment of Health sent her a let­ter say­ing the state wouldn’t al­low abor­tions to be per­formed in a surgery cen­ter. Burkhart and her lawyers re­sub­mit­ted their ap­pli­ca­tions. “Now they’re say­ing you can’t do abor­tions in a more highly reg­u­lated en­vi­ron­ment!” Burkhart says in Oc­to­ber. “I al­ready have in­vested in this pro­ject—just cash, well over $100,000.” She checks her e-mail again, hop­ing to find a mes­sage from the health depart­ment, which said she’d get word by that day. “We’re on pins and nee­dles,” she says.

In De­cem­ber, Burkhart re­ceived ini­tial ap­provals, and de­mo­li­tion be­gan. Con­struc­tion started in Jan­uary. If all goes ac­cord­ing to plan, the state will in­spect the site twice in the com­ing months, and the clinic will be open by sum­mer.

The Amer­i­can Med­i­cal As­so­ci­a­tion and the Amer­i­can Congress of Ob­ste­tri­cians and Gyne­col­o­gists have filed le­gal briefs in the com­ing Supreme Court case call­ing ASC re­quire­ments un­nec­es­sary and il­log­i­cal.

In 2013, Texas re­quired that abor­tions be per­formed in am­bu­la­tory surgery cen­ters. A spokes­woman for Whole Woman’s Health says it called ev­ery ASC in Texas ask­ing if it could rent their space af­ter-hours. All 250 de­clined. The monthly over­head for op­er­at­ing its sin­gle ASC in Texas runs $40,000 higher per month than a stan­dard clinic. In 2015 the com­pany opened a clinic in New Mex­ico to serve the women of West Texas.

In Ohio, Burkons was the only OB-GYN to open a clinic pro­vid­ing sur­gi­cal abor­tions in at least the past five years. When he be­gan per­form­ing abor­tions at North­east Ohio Women’s Cen­ter in Au­gust, it was af­ter 18 months of back-and-forth with the Ohio Depart­ment of Health, which he es­ti­mates cost him about $100,000. Burkons has been prac­tic­ing medicine since 1973. In 2013 he de­cided to take over a clinic clos­ing in Cuyahoga Falls that in­cluded a surgery cen­ter. Burkons started pay­ing the build­ing’s $2,500 monthly rent and took out mal­prac­tice in­sur­ance. A col­league from an­other clinic ad­vised hir­ing a con­sul­tant to help him pass the state in­spec­tion re­quired of all ASCs when they re­open un­der new man­age­ment. “I thought, Eh, I don’t need it. We know what’s wrong, and we’ll fix it. Why spend the money?” Burkons says. “I had been work­ing in the abor­tion field. I was well-versed in it. I was very naive in fig­ur­ing that [the Depart­ment of Health] is a state agency and they’re go­ing to treat you fairly.”

Ohio Depart­ment of Health doc­u­ments ob­tained by Burkons’s at­tor­ney show that 33 other health-care fa­cil­i­ties that ap­plied for li­censes from 2011 to 2015 waited a me­dian of about 15 days be­tween be­ing in­spected and re­ceiv­ing a li­cense or a plan of cor­rec­tion that led to a li­cense. Five months af­ter his in­spec­tion and pres­sure from his at­tor­neys, whose $400-per-hour rates quickly added up to about $15,000, the Ohio Depart­ment of Health told Burkons that be­cause of six vi­o­la­tions, it was deny­ing his li­cense. Ac­cord­ing to a list of ASC li­cense re­quests is­sued by the state, all seven of the other sur­gi­cal cen­ters cited for vi­o­la­tions from 2011 to 2015 were not de­nied and were al­lowed to make im­me­di­ate corrections.

Burkons at­tributes the height­ened scru­tiny to pol­i­tics: In 2012, Gov­er­nor John Ka­sich ap­pointed Ohio Right to Life’s pres­i­dent, Michael Gonidakis, a lawyer with no med­i­cal back­ground, to the state’s med­i­cal board, which over­sees physi­cian li­censes. Kather­ine Franklin, a spokes­woman for Ohio Right to Life, says that in 2013 her or­ga­ni­za­tion, with Gonidakis at the helm,

suc­cess­fully lob­bied the Univer­sity of Toledo Med­i­cal Cen­ter to de­cline Burkons’s ad­mit­ting priv­i­leges—a new state re­quire­ment for physicians per­form­ing abor­tions. But Gonidakis’s po­si­tion on the state med­i­cal board wouldn’t have af­fected a physi­cian’s ap­pli­ca­tion to pro­vide abor­tions, Franklin says.

Af­ter the li­cense was de­nied, Burkons reap­plied. Be­fore the se­cond in­spec­tion, he hired con­sul­tants for $12,000. They rec­om­mended go­ing over­board; if the guide­lines called for three smoke alarms, they ad­vised hav­ing six. When the state in­spec­tors were done, Burkons says, they told him, “We’re go­ing to sub­mit there are no vi­o­la­tions. Nor­mally you’ll have your li­cense within two or three weeks. This isn’t nor­mal. Good luck.” Five months later, in July 2015, Burkons found out he’d been granted his li­cense from an ac­quain­tance, who’d read the news on the Ohio Right to Life web­site. “There were many days when I would think, What the heck did I do this for?” he says. But pro­vid­ing abor­tion care is grat­i­fy­ing, be­cause ev­ery pa­tient “comes in with a prob­lem and leaves with­out a prob­lem,” Burkons says. “Where else in medicine can you, mul­ti­ple times a day, change a woman’s life in five min­utes?”

Govern­ment regulation is one ob­sta­cle to clin­ics’ pro­vid­ing abor­tions, but the pri­vate sec­tor presents oth­ers. Non­prof­its have swooped in to sub­si­dize abor­tion care in the ab­sence of pub­lic funds; to stay com­pet­i­tive, for-prof­its must mir­ror non­profit prices. At many clin­ics, a pa­tient in­ter­acts with an ad­min­is­tra­tor, nurse, sono­g­ra­pher, coun­selor, and physi­cian—dur­ing each of at least two vis­its in 13 of the states with manda­tory wait­ing pe­ri­ods—all for just a few hun­dred dol­lars. Hagstrom Miller says Whole Woman’s Health op­er­ates at a 1 per­cent or 2 per­cent profit or at a loss. “We have made it next to im­pos­si­ble to keep our doors open just from pa­tient re­ceipts,” she says. “In some ways, we’ve done that to our­selves by be­ing so com­mit­ted to the so­cial jus­tice and hu­man-rights part of our work and know­ing the women we serve can’t af­ford those fees.”

When Burkhart opened South Wind, she raised enough in do­na­tions to ren­o­vate the fa­cil­ity but still needed a line of credit for ev­ery­thing else. “I spent two years talk­ing to dif­fer­ent fi­nan­cial in­sti­tu­tions,” she says. “I went from small, very lo­cal banks to re­gional banks to Bank of Amer­ica, Wells Fargo.” Lenders may have re­jected Burkhart’s loan ap­pli­ca­tions be­cause of abor­tion stigma or le­git­i­mate fi­nan­cial con­cerns; it’s of­ten hard to dis­en­tan­gle the two. (In an e-mail, a Wells Fargo spokesman said the bank can’t share cus­tomer in­for­ma­tion; a Bank of Amer­ica spokes­woman said in an e-mail that the bank had no in­for­ma­tion on South Wind.) A clinic di­rec­tor in the South, who asked not to be iden­ti­fied for fear of ha­rass­ment, says that when she ap­plied for a loan, a bank rep­re­sen­ta­tive asked her if the state was go­ing to pass laws that would close her prac­tice.

South Wind al­most breaks even, tak­ing in about $1 mil­lion a year. In ad­di­tion to con­struc­tion, staffing is a ma­jor cost for clin­ics. For her Ok­la­homa City lo­ca­tion, Burkhart an­tic­i­pates hir­ing four ad­min­is­tra­tors, two or three doc­tors, and five or six other med­i­cal per­son­nel. The mar­ket rate for a nurse in Ok­la­homa City is $60,000; a lo­cal OB-GYN on av­er­age makes $250,000. Still, Burkhart says, “On pa­per, we look pretty good.” She hoped that run­ning the Wi­chita clinic debt-free would make fi­nanc­ing the Ok­la­homa clinic eas­ier, but it took a year to find a re­gional bank will­ing to pro­vide a loan for one-third of the con­struc­tion costs. She won’t name the bank. “I don’t want them to have to un­dergo any con­flict,” she says.

Burkhart isn’t para­noid. Anti-abor­tion or­ga­ni­za­tions closely mon­i­tor and pub­li­cize lo­cal busi­nesses’ deal­ings with abor­tion clin­ics. One such group is Wi­chita-based Op­er­a­tion Res­cue, whose work, ac­cord­ing to its web­site, is “tak­ing di­rect ac­tion to re­store le­gal per­son­hood to the pre-born and stop abor­tion in obe­di­ence to bib­li­cal man­dates.” Says its pres­i­dent, Troy New­man: “We do ev­ery­thing le­gal and moral to make sure th­ese abor­tion clin­ics aren’t able to open up. We’ll talk to land­lords. We’ll talk to neigh­bors. We’ll send post­cards out ask­ing not to rent, lease, or sell to an abor­tion­ist.” Con­way, of Texas Right to Life, says that when anti-abor­tion or­ga­ni­za­tions in her state “hear a rum­bling” about an abor­tion clinic com­ing to town, ac­tivists will go to the lo­cal per­mit of­fice “al­most on a daily ba­sis” un­til doc­u­ments with con­trac­tors’ names are avail­able. Then they blast the con­trac­tors with phone calls and or­ga­nize boy­cotts.

Kansas Coali­tion for Life pro­test­ers dis­sem­i­nate any names they see printed on the ve­hi­cles in South Wind’s lot. The day Burkhart’s ar­chi­tect ac­cepted the job at South Wind, he dis­abled his home an­swer­ing ma­chine; he’d re­ceived an­gry calls from across the coun­try.

A clinic di­rec­tor in the South says she spends un­told hours deal­ing with prob­lems that would be easy to solve if lo­cal busi­nesses were will­ing to work with her. She taught her­self to re­pair a hy­draulic bed be­cause no lo­cal handy­man would come by. Whole Woman’s Health has a full-time staffer des­ig­nated for wran­gling ven­dors. When it opened the clinic in New Mex­ico, the phone com­pany in­staller re­peat­edly stood up the staff for three months. La­mar Bill­boards re­scinded a con­tract to sell Whole Woman’s Health ad space ex­plic­itly be­cause the com­pany pro­vides abor­tions, says Fa­timah Gif­ford, a spokes­woman for Whole Woman’s Health. (La­mar de­clined sev­eral re­quests for com­ment.)

None of th­ese ob­sta­cles by them­selves is enough to pre­vent a clinic from pro­vid­ing abor­tions, but their cu­mu­la­tive ef­fect can shut­ter clin­ics by rais­ing the dif­fi­culty and cost of do­ing busi­ness to un­sus­tain­able lev­els. “If any­body asked me, ‘Should I try this?’ I’d prob­a­bly tell ’em no,” Burkons says. <BW>


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