In Cleveland, a Planned Parenthood mobile clinic that tests for sexually transmitted diseases has reduced its hours and may shut down. In Minneapolis, women and girls used to free check-ups are now billed as much as $200 per visit on a sliding fee scale. And in Vienna, West Virginia, Planned Parenthood employees are marking boxes of birth control pills with “Do not use” signs because they were paid for with federal grants the organization can no longer accept.

Planned Parenthood’s decision this week to quit a $260 million federal family planning program rather than comply with what it calls a “gag rule” imposed by the Trump administration on abortion referrals is creating turmoil in many low-income communities across the United States.

The organization had served 1.5 million women, or about 41 percent of the participants in the Title X program, providing reproductive health services, such birth control, pregnancy tests and screening for sexually transmitted diseases at free or discounted prices.

While some lucky patients will find the transition relatively seamless if they live in states such as Washington and Vermont that have dedicated funds to make up for the shortfall, many others will face long delays, higher costs and possible clinic closures.

Planned Parenthood officials say they are doing all they can to work with individual patients so that they can continue to get care – training employees to help those eligible to sign up for Medicaid, working out financing plans, or referring patients to other low-cost clinics. They have also launched new fundraising efforts to keep the programs going. Many clinics have posted placards outside their doors that reassure women that “We’re here to stay. We’re here for you.”

Leaving the Title X program was not a decision Planned Parenthood made lightly. The country’s largest U.S. abortion provider, which has been a longtime target of religious conservatives, has been fighting the rule changes in court, private meetings and through public protests for more than a year.

But a decision last week from the Department of Health and Human Services to require participants in the program to pledge to abide by the rules and provide a plan for coming into compliance by Aug. 19 forced a decision. Alexis McGill Johnson, acting president and CEO, Planned Parenthood Federation of America, said the group could no longer participate in a program they believe is forcing doctors, nurses and other care providers to withhold information in a way that is unethical and dangerous to women’s health.

“We believe that the Trump administration is doing this as an attack on reproductive health care and to keep providers like Planned Parenthood from serving our patients,” Johnson said.

In recent weeks, several states which distribute Title X funds – including Delaware, Rhode Island, Michigan, and Virginia have said they will remain in the program – while New York, Oregon, Washington, Illinois and Hawaii have said they would not. A Planned Parenthood clinic in Vermont, which is the only federal family planning provider in the state, was saved at the last-minute Monday from a reduction in services when the state said it would pay $759,999 to keep the clinic fully operating.

There have been no such reprieves for clinics in West Virginia, Minnesota and Ohio.

In Minneapolis on Wednesday, Jessica DeLong walked into the Planned Parenthood in Minneapolis for birth control and was told she’d have to pay $200 instead of her usual $30 co-pay. She didn’t have it, and told the clinic she’d come back next week after she got paid.

“I just feel like they’ve targeted Planned Parenthood,” she said.

Kaitlyn Vaske-Wright, a nurse practitioner, said other patients had already left the clinic or canceled appointments because they could not afford to pay more. In addition, she said, some patients are limiting their care for monetary reasons.

“They come in with a specific problem they need addressed, and I might recommend testing A, B, C and D, and due to cost, they might only choose to do A or B, which in my professional opinion would not be the best plan of care,” she said.

“Patients are confused and frustrated,” Vaske-Wright added.

Another patient, Rasheeda, said she felt worried as she entered the clinic for her appointment. She receives birth control, medical care, as well as counseling at Planned Parenthood.

“I just feel like it’s going to be very hard for women,” Rasheeda said. “If you don’t make that much income, how are you going to be able to support the needs and the health from here?”

There was similar anxiety among patients in Cleveland. A Planned Parenthood mobile clinic RV was parked at a public housing complex on Thursday when two young women walked up. Destiny Woodson, an 18-year-old high school student who works part-time at Dunkin’ Donuts, asked for some condoms.

When she found out the HealthMobile might end its run because of the funding loss – its coordinator had already been made part-time – Woodson was indignant.

“That’s not right, that’s not right at all,” she said.

Woodson’s friend, Ashanti Zeigler, 20, shifted her 1-year-old son, Josiah, in her arms, as she lamented the lost funding. “I don’t like it,” Zeigler said. “Why take away something from people who can’t afford it? And why should Trump be able to tell women what we can do with our bodies?”

Planned Parenthood of Greater Ohio, which received $4 million in the last Title X grant cycle and serves 60,000 patients, said it is looking at closing its HealthMobile program which it has run with Cleveland’s Health Department for nine years. The 20-year-old RV goes out into the city’s poorest neighborhoods, parking near recreation centers, schools, and laundromats. Outside, a sandwich-board sign announces: “Free Health Services Available. Pregnancy Testing, STD Testing. HIV Testing. Condoms.”

At the Planned Parenthood in Vienna, West Virginia, employees boxed up various supplies, including birth control pills and shots, that had been purchased with Title X funds to be given to clients at no or low-cost. In some cases, the clinic has had to write prescriptions which are now filled elsewhere, often at a significant cost to patients. Those able to wait have been rescheduled while the clinic tries to find other ways to get the supplies.

“That actually posed a big problem for us,” said health center manager, Elizabeth Boothe.

Madeline Gray, 25, was at the Vienna Planned Parenthood Monday afternoon, shortly after the agency announced it was leaving the family planning program. Gray, who is uninsured, and has relied on Planned Parenthood since she was a teenager for annual exams, testing, and birth control. She had come in to get her IUD replaced.

“I signed in, and they said, ‘We don’t have it. We just lost our Title X funding,'” she said. “And I knew that, but I thought that was going to be a slower process. I am putting my savings into an IUD instead.”

She said she is has mixed feelings about Planned Parenthood’s decision.

“I do support it because they would still be denying women care if they were to change their rules … I just hate that because of that so many women are going to lose out on health care. It’s a ‘damned if you do, damned if you don’t’ situation,” she said.

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