Faced with the biggest blow to reproductive health care in half a century, abortion advocates are promising to help people who need the procedure but suddenly find themselves stranded in states that don’t allow it.
Yet meeting the expected surge in demand from across blue-state borders will be tough — even after anticipating for months that the highest court would reverse Roe v. Wade, the 1973 decision that made abortion legal nationwide.
Abortion facilities face daunting challenges. Costs to keep clinic doors open can be prohibitive. Providers can experience price gouging for supplies, rent and liability coverage.
They face shrinking reimbursements from insurance companies and Medicaid. Ever-changing legislation and zoning laws require clinics to renovate or relocate to comply with byzantine rules. A shortage of health care workers means that some facilities that want to expand don’t have the staff to do so.
About half of all abortions — the latest available data say about 300,000 in 2019, including medication abortions — were performed in states considered hostile to the procedure. Without Roe’s constitutional guarantee, 26 states are likely or certain to ban the procedure or tighten existing restrictions, says the Guttmacher Institute, which researches reproductive rights. Such laws will further jeopardize access for more than 33 million child-bearing people.
While slightly more than half of U.S. abortions are now done through medication, that process comes with its own restrictions. Nineteen states, for example, require patients to take pills in the presence of a doctor.
“This is going to put huge pressure on those states and those clinics” providing care, said Lori Brown, a Syracuse University professor who studies abortion-related legislation. “I don’t know that they’ll be able to meet the demand that this is going to create. It’s going to create such an unequal system of access.”
Illinois could become one of the country’s leading destinations for abortion seekers, given that it’s surrounded by states poised to make the procedure illegal now that Roe is overturned. The number of women between the ages of 15 and 49 whose nearest provider is in Illinois could increase by more than 8,000%, according to the Guttmacher Institute.
Maryland is also likely to see a big uptick. On a Tuesday in late May, the out-of-state patient surge had already hit Whole Woman’s Health in Baltimore. Weeks before the Supreme Court struck down Roe, the clinic was bustling.
Five patients sat in the darkened lobby on their phones or filling out forms, and another lined up at the check-in desk. Several more were buzzed in over the next hour. Staff took patients through a door to the back, where nearly a dozen workers in scrubs moved quickly in and out of the many rooms that lead off a main hallway, painted millennial pink and covered with posters bearing inspirational quotes.
“A lot of the times it's like we're just little bees in a hive buzzing around the clinic because we're all moving so fast,” said Savanna Hellman, a social worker who speaks with each patient before the procedure. She said she was seeing a lot more people from states like Texas, which as of September banned abortions beyond about six weeks of gestation. Many of the out-of-state patients, she said, complain about the stress of flying, finding child care and organizing logistics.
“We still have our Baltimore patients to see, we still have patients from nearby states to treat, on top of all these Texas patients” and others from distant places, said Hellman. “We're trying to see as many people as we can. We're trying not to turn anyone away.”
‘It’s very difficult to find people who are willing to do this and who do it well.’
To cope with the demand, the clinic plans to extend its closing time by two hours to 4 p.m., Hellman said. But a major expansion of its patient load isn’t likely: The clinic doesn’t have dedicated doctors on hand to provide abortion care — all fly in from other locations.
But at least Whole Woman’s Health is operational. That’s not yet the case for the new abortion clinic that Diane Horvath, an obstetrician-gynecologist, has been trying since late last year to open about 30 miles south in College Park, home to the University of Maryland.
Horvath and her business partner, Morgan Nuzzo, a nurse-midwife, hope to start Partners in Abortion Care and offer all-trimester abortions, which are allowed under Maryland law. About 1% of abortions are performed after 21 weeks, according to data from the U.S. Centers for Disease Control and Prevention. After 29 weeks, only a handful of clinics offer the procedure, causing long waits for patients who need them, often because of a fetal anomaly or other medical issue.
As of July, Maryland will also allow midwives like Nuzzo to perform abortions. "We want to open as soon as we can because we know capacity is down and folks don't have a place to go," Horvath said.
Money has been the biggest obstacle. “One thing that has been really surprising and really disappointing is there are a lot of funders out there who are saying they want to put money into clinics and increase capacity in friendly states,” Horvath said. “But when it came down to it, our ability to get those funds was really limited.”
A major snag is that most donors want their money to go to nonprofit organizations to get the tax benefit. But creating a nonprofit is too much work for a small group like Partners, Horvath said.
Partners secured a $200,000 loan in April — less than 20% of what it needs to open. It then turned to another source for capital: a crowd-sourced fundraiser through GoFundMe. By mid-June, Partners had raised more than $260,000 and upped its goal to $500,000.
To keep costs down, Horvath and Nuzzo have bought second-hand clinic supplies, such as ultrasound equipment and an exam table from a cardiologists’ office that was shutting down. Nuzzo rented a U-Haul truck to pick up the equipment, which now sits in a storage locker. “We wanted to be as economical and budget conscious as possible,” Horvath said. “This is all very scrappy.”
Partners, which expects to open its doors later this year, is swimming against the tide. Ten years ago, there were 510 stand-alone clinics, according to Abortion Care Network, a national network of independent providers. As of November, there were only 358. Yet independent clinics like Partners still perform nearly 60% of abortions in the US. A little over a third are done at Planned Parenthood centers and a small number are performed at hospitals or in doctors’ offices.
Even in some blue states — 16 of which have laws that protect the right to an abortion — clinics can face political backlash at the local level. That’s true for California, where Gov. Gavin Newsom has proposed spending $125 million to make abortion more accessible.
Planned Parenthood Mar Monte’s facility in Visalia already offered family planning services and wanted to add abortion care at a new 6,500 square-foot clinic. That way it wouldn’t have to send abortion-seeking patients an hour away to Fresno or Bakersfield.
The facility had gotten an all-clear from the city planning commission, but a nearby business owner objected to the plan, citing traffic snarls that he said protestors would cause. And then dozens of residents in the city, about 200 miles north of Los Angeles, pushed back in a city council meeting in March. Some opponents said abortion didn’t line up with local values and others maintained there were enough local reproductive health care providers.
The city council ultimately killed the plan, according to Lauren Babb, spokesperson for the Mar Monte network, the largest Planned Parenthood affiliate in the U.S., with more than 30 health centers in mid-California and northern Nevada.
The Visalia clinic still plans to expand, Babb said, though it’s unclear when or how that will happen. Mar Monte’s clinics have been “preparing for this moment for a very long time,” she said, adding that telemedicine for initial intakes will be a key part of its plan. The network had 144,419 telehealth visits in 2021, up from 115,330 the year before. In the 10 months ending in April, the group has provided abortion care to 80 out-of-state patients, double the usual amount.
Warren Hern, a physician who has been performing abortions in Colorado since Roe was decided in 1973, saw his patients double in number after the Texas law took effect. He calls this “one of the worst times” in his career for restrictions.
His facility, Boulder Abortion Clinic, sees people who need abortions later in pregnancy, including in the third trimester. Hern said he’s looking to expand his services but his practice is in an older building that isn’t conducive to that, and it’s hard to find enough staff to bring on board.
“It’s very difficult to find people who are willing to do this and who do it well,” Hern said. Because third-trimester procedures are more complex and often take place over several days, that limits the number of patients he can take on. “If we have 10 patients on the schedule, it’s like seeing 50 or 60 patients.”
“Expanding my services is an objective and we’re working on that, but that’s going to take a long time,” Hern said. “The ripple effect is that across the country, a lot of women will not be able to get abortions.”
