Abortion Access in a Post-Dobbs America

Access to abortion is necessary for health and well-being. The recent Supreme Court decision in Dobbs v. Jackson Women’s Health Organization will have devastating impacts on the future of abortion access in the United States. As an abortion scholar and advocate, I was gutted by the majority opinion declaring that “the Constitution does not confer a right to abortion; Roe and Casey are overruled.” This legal interpretation will not stop the movement for reproductive justice or the commitment of clinics to provide care. Addressing reproductive health inequalities requires us to embrace and embed abortion care in health provision and policy. 

Who has abortions?

One in four women will obtain an abortion at a medical provider in their lifetime. People of all identities have abortions as the reproductive capacity for pregnancy is not determined by gender, sexuality, race, religion, or political ideology. The profile of a typical abortion patient in the United States reflects the reality of current abortion restrictions and tells us where we must focus on efforts to help people access care. Most abortions happen in the first 13 weeks due to state-level gestational limitations. Patients often prefer to obtain care early in pregnancy but face numerous challenges navigating state requirements that require multiple trips and mandatory waiting periods.

Where does abortion happen?

Abortion care is not embedded in mainstream medicine. Specialized clinics provide 95% of abortions, and three out of five abortions are provided by independent abortion clinics. An independent clinic is a provider that is not affiliated with Planned Parenthood. Independent clinics represent 25% of facilities nationwide and are often located in places most hostile to abortion. When the abortion clinic in my city closed after nearly 40 years of practice, we asked indie provider Whole Woman’s Health to return care to our community because they have a record of overcoming state restrictions and funding challenges. Our story was exceptional because once an abortion clinic closes in a community, local access is rarely restored. The Abortion Care Network found that after years of extreme abortion restrictions and legal challenges to Roe, 113 independent abortion clinics closed between 2016-2021. Few facilities are able to provide care after 13 weeks, and the independent clinics that closed in the last two years provided 74% of care after the first trimester. Abortion bans following the Dobbs decision will only accelerate the rate of clinic closure and loss of vital care infrastructure in the United States.

Who provides abortion care?

Abortion provision has been eroded by government restrictions and violent opposition that created vast workforce factors that limit who provides care. Providers face deadly violence, criminalization, stigma, and professional penalties. Most practicing obstetrician-gynecologists have patients who request abortion services but cannot provide care themselves. The next generation of physicians is at risk of continuing this trend and never learning full-spectrum reproductive care skills. A review of accredited OB-GYN programs estimated that almost half of all current residents are certain or likely to lack access to in-state training resulting from abortion bans following Dobbs. Licensed physicians must perform all abortions in 35 states. These states ban abortion from the scope of practice for other medical professionals who can safely and effectively provide abortion care. Under Massachusetts law, physician assistants, nurse practitioners, and nurse midwives may perform abortions “consistent with the scope of their practice and license if, in their best medical judgment, the pregnancy has existed for less than 24 weeks.” Access to abortion is expanded when everyone who can provide care does provide care.

How will abortion care change if/when state bans go into effect?

Over 200 abortion providers in 26 states are expected to close if state bans are allowed to go into effect – 25% of abortion facilities nationwide. These closures would cause a near-total loss of abortion provisions in the South and Midwest. The greater the distance between someone’s home and the nearest abortion provider, the more likely they are to be denied or delayed care. Restricting and concentrating abortion care in half the country is inequitable to patients and places enormous strain on the remaining providers.

Abortion care will be different post-Dobbs than it was pre-Roe. Medication and telehealth advances have increased options for safe at-home abortion care. However, 27 states restrict or ban telehealth abortion care. There is no medical reason for these bans; telehealth abortion care is as safe as in-clinic care. There is a growing need to make abortion pills available over the counter. Studies show that people can self-assess the timing of their pregnancy and comprehend abortion pill packaging. Organizations to help people end a pregnancy outside of a medical setting mobilized after the Texas ban last fall and have expanded to other places where the state has terminated rights and eliminated access to clinics.

The legal landscape of abortion has been rapidly changing and confusing as courts decide which state bans can be enforced and new laws are passed. Abortion helplines have been flooded with calls from people desperate to arrange care as clinics are forced to pause services depending on the legality of the practice. Confusion and hesitation on the legality of care harm patients. The Texas ban had a chilling effect on healthcare professionals state-wide, who feared they could not even talk about abortion and left patients to find care on their own. A pregnant woman in Boston was recently denied an abortion because her doctors interpreted the Roe Act as not applying to her condition and circumstances.

Who will state abortion bans impact the most?

40 million women live in places where state legislators are actively pursuing the enforcement of abortion bans and terminating reproductive rights. Communities of color and low-income households are at most risk from the harm of abortion bans. We know from the Turnaway study that “being denied abortion care worsens health, financial, and family outcomes.” Due to racism and inequalities in our health systems, women of color are more likely to experience poor health outcomes and barriers to care than white women across all reproductive and maternal health needs. Banning abortion furthers the criminalization of pregnancy and the overcriminalization of women of color in the United States. 

After Roe, many abortion policies to restrict abortion provision and payment included exceptions for two circumstances of pregnancy. Lifesaving exceptions allow physicians to decide if abortion is the only intervention able to save the pregnant person. There is no standard practice among medical professionals to determine what “lifesaving” means. Medical professionals are put in a harmful position to decide how close to death people need to be to qualify for a lifesaving abortion. Under the national policy of Roe, exceptions for pregnancies resulting from rape or incest were rarely used as sexual assault is massively underreported to authorities. Abortion exceptions for sexual violence are practically impossible to receive, and forcing survivors to carry a pregnancy to term is impossibly cruel. Abortion exceptions once considered essential are being eliminated by state governments. Reversing Roe places access to abortion beyond reach for many, and eliminating exceptions removes the possibility of lifesaving interventions closer to home.

What is the biggest barrier to accessing abortion?

Cost – many abortion patients experience poverty-level income constraints that make affording abortion a primary barrier to care. Due to Medicaid and private insurance restrictions, most patients must pay out-of-pocket for care which can average about $500 in the first 13 weeks. Medication and procedural abortion within the first trimester have similar costs; care becomes more costly as pregnancy progresses. Although abortion provision has become more expensive for providers to meet medically unnecessary state regulations, the cost of care paid by patients has not significantly increased in the last 30 years. Providers want abortion as affordable as possible to expand access to all who need care. Travel adds to the cost of care, and people in places without local abortion access may need to travel 500 miles or more to reach a provider. Over half of all abortion patients are already parents and will need to arrange childcare during the time it takes to reach their appointments and complete care.

Affording the cost of care, travel, and time away from work and family to obtain an abortion is a public health crisis that will intensify under state abortion bans. Most households in the United States are unable to pay a $400 emergency expense – less than an abortion would cost. Abortion funds are experts at helping people overcome the logistical and financial barriers to care. These nonprofits are largely run by volunteers and are severely under-resourced to meet growing needs. An estimated $99 million in additional funding will be needed to cover the cost of abortion procedures each year if expected state-level abortion bans go into effect. People with the capacity for pregnancy should not be expected to save in case of abortion, nor should our medical systems require a network of aid to overcome barriers to care.

What can we do to advance abortion access?

Abortion providers, medical students, doulas, advocates, lawyers, and policymakers prepared for Roe to fall. The Biden-Harris administration announced two actions following the Dobbs decision to protect the right to travel across state lines for abortion care and access to medication for contraception and abortion. HHS issued additional guidance to protect patient privacy that falls short of advocates’ demands to safeguard the data of people seeking an abortion. The White House can and must do more to address the crisis of abortion care. Proposed ideas include establishing clinics on federal land, issuing travel vouchers, and expanding telehealth for medication to be issued through the mail. Congress was unsuccessful in codifying Roe, but that has not stopped Senator Warren and others from introducing a bill to stop anti-abortion disinformation. As the political fervor for “abortion abolition” seeks a national abortion ban, our policymakers must meet this moment to protect access.

As academics and policy scholars, we must continue to invest in reproductive health equity knowledge. Tufts launched The Center for Black Maternal Health and Reproductive Justice to foster community-engaged maternal health research that eliminates inequalities. Advancing New Standards in Reproductive Health (ANSIRH) is a powerhouse of abortion scholarship, and their work has populated my citations and syllabi. ANSIRH researchers applied the 10 Essential Public Health Services framework to outline how community health professionals can support people seeking abortions.

The Black Reproductive Justice Policy Agenda, NIRH Local Reproductive Freedom Index, Interrupting Criminalization, and the Center for Advancing Innovative Policy provide roadmaps to advancing reproductive equity through policy. My policy students last semester provided a beacon of hope in this challenging work. Students produced nuanced and compassionate policy analyses to center on the needs of those most impacted by complex social problems. In a post-Dobbs America, it is more important than ever that we train the next generation of health policy analysts and system scientists to advance abortion access.

If you, or a loved one, needs care, visit www.ineedana.com to find nearby abortion providers. Call the All-Options Talkline at 1-888-493-0092 to speak to someone about pregnancy options.

Jamie Morgan is an instructor at the Tufts University School of Medicine and doctoral candidate at the Heller School for Social Policy. Her forthcoming dissertation research examines the effects of contentious politics on gender-based violence at abortion clinics. Special thanks to MPH/PA students Laura Kostos and Mariella Medina for their insights that improved this piece.