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Abortion

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Caroline Catherman

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Angel Foster only enters the US via Canada, where she’s a professor. She doesn’t drive a car outside Massachusetts. And she doesn’t visit Florida, South Carolina, or other states that ban or restrict abortion.

These are the precautions this MD takes as founder of the Massachusetts Abortion Access Project (the MAP). It’s a service that prescribes and ships abortion medication via telehealth under Massachusetts’s shield law, which protects those physically present in Massachusetts from out-of-state penalties for accessing or assisting with abortion care.

Legal challenges to providing abortions via shield law have popped up over the last few months, but Foster and others 

. Foster envisions a future with even more providers working similarly from other states that have comprehensive shield laws.

“We have been trying to identify folks in those states who are willing to provide [this care], and then work with them to build out a practice so that they don’t have to reinvent the wheel,” Foster said. “They can piggyback on a lot of the things that we’ve learned.”

Twenty-two other states and Washington, DC, currently have shield laws, according to the University of California, Los Angeles School of Law. Eight of those—California, Colorado, Maine, Massachusetts, New York, Rhode Island, Vermont, and Washington—

 protect telehealth abortion even if the recipient is located in a state where it’s illegal for them to get care.

The Supreme Court struck down constitutional protections for abortion 

. The MAP was founded in September 2023. It serves 2,000 to 2,500 patients a month, 95% of whom are from states with bans and restrictions, Foster said. In 2024, about 10,000 abortions in the US were provided under shield laws each month, according to the nonprofit research organization the Society of Family Planning’s #WeCount tracker.

Though not a prescriber herself, Foster still faces a risk of prosecution if she leaves the state of Massachusetts. The MAP’s five prescribers know the risks, too. “I think we all went into working in the shield law space with the expectation that there would be a lawsuit at some point,” Foster said.

Beyond Foster’s practice, telehealth abortions are growing rapidly, making up to 

 by the end of 2024, compared to 19% at the end of 2023 and 7% at the end of 2022, according to #WeCount.

 found that this form of treatment is just as safe and effective as in-person abortion.

No one has been jailed for providing a telehealth abortion to someone in a state where the procedure is banned.

Recently, however, 15 attorneys general from banned states signed a 

“These laws are blatant attempts to interfere with states’ ability to enforce criminal laws within their borders and disrupt our constitutional structure,” they wrote.

 against a New York doctor who allegedly prescribed pills to a minor in the state. So far, New York’s governor has held strong and refused to turn the doctor over for prosecution. This, and the MAP’s close working relationship with the Massachusetts government, gives Foster hope.

“We’re feeling very confident about the ability of the Massachusetts shield law to protect us,” she said.

White pills floating across between two phones with a checkmark on one screen. Credit: Anna Kim

Abortion shield law provider encourages others to follow her lead

Recent laws have challenged the practice, but that isn’t deterring providers.

Cassie McGrath

, the Centers for Medicare and Medicaid (CMS) announced in a statement it would rescind 2022 guidance from the Biden administration that allowed patients to have abortions in emergency situations.

Former President Joe Biden sought to override state laws banning abortion and ensure pregnant people had access to reproductive care in emergencies, like if their life was at risk.

Biden’s guidance cited the Emergency Medical Treatment and Active Labor Act (EMTALA), a national law that requires hospitals to examine and treat all patients even if they can’t pay for their care. Under CMS’s new directive, EMTALA is still in place as federal law and encompasses treating “identified emergency medical conditions” for a pregnant person and/or an unborn child, but the federal government is no longer directly asking states to provide abortions during emergencies.

As a result, some experts worry a lack of directive could lead to more 

Melissa Simon, an ob-gyn at Northwestern Medicine in Chicago, told us she is “deeply concerned” about CMS’s decision.

“The current administration is trying to rescind this but is not changing the EMTALA law, which still obligates hospitals to provide emergency care,” she said. “However, what this will do is promote more confusion, which leads to a dangerous climate of legal uncertainty under which physicians and health professionals should not operate.”

Even with Biden’s guidance in place, the 

 reported last August “dozens” of pregnant people have been turned away from emergency rooms since the 

 ruling, including patients with life-threatening pregnancy complications. In some cases, 

In the June 3 announcement, CMS said it would enforce EMTALA, which protects patients who show up to emergency departments seeking treatment, including cases where a pregnant person and/or their unborn child is “in serious jeopardy.”

 from former Department of Health and Human Services Secretary Xavier Becerra that explicitly directed clinicians to provide abortions if “stabilizing treatment” is required to resolve a medical issue.

Simons said the new CMS’s guidance “undermines” clinicians ability to provide “evidence-based life-saving care without delay or discrimination,” and that patients will now be exposed to higher pregnancy health risks. She also said this may erode trust between patients and their providers.

“No patient should be forced to suffer, and no healthcare provider should be forced to choose between their oath and the law,” she said.

A clinic chair and monitor on a sound block with large sticky notes placed around. Credit: Anna Kim

New CMS directive adds legal confusion for pregnancy care in cases of emergency 

CMS creates more confusion and revokes Biden-era guidance to allow abortion care for patients experiencing emergency health concerns. 

June 24 marks nearly three years since the 

Dobbs v. Jackson Women’s Health Organization

 decision that overturned the constitutional right to abortion in the US.

 have banned or restricted abortion before fetal viability across the country, according to the NYT abortion law tracker. Independent abortion clinics in some states are 

, while companies offering telehealth have seen a 

. At the same time, maternal mortality rates 

, and stories have emerged about pregnant 

We spoke with reproductive health experts around the US to learn more about how maternal care has changed in the last three years. Here’s what they told us.

These interviews have been edited for length and clarity.

Melissa Simon, ob-gyn at Northwestern Medicine in Chicago, where abortion is legal

In states that are supportive of reproductive care and health, care hasn’t changed with respect to the quality of care. It’s more volume based. The volume of care has increased with patients coming from other states, and some of them travel very long distances from all over the country.

Any clinician who’s trying to get trained in reproductive health of any form can’t get trained well—or let alone at all—in states where they passed restrictive laws as a result of the overturning of 

. That leaves half the country pretty much unavailable for access to training, which is a real problem when about 50+% of the US population is female.

People get triggered or emotional around the word abortion, and they connect it to so many other things, but in reality, women’s health care is being completely demolished and undermined because of emotion connected to a word.

Monica Ruehli, clinical director of reproductive and gender-affirming health at Blue Cross Blue Shield of Massachusetts, where abortion is legal

We developed our own internal reproductive health and gender-affirming team just after the 

 decision, and that was one of the factors that led us to really concentrate and think more about women’s health. Luckily, here in Massachusetts, we have a huge commitment to reproductive health and gender-affirming care by our governor and at the state level.

There are still a lot of people who are traveling to Massachusetts for abortion care and that the state has seen a huge number of people coming in, especially initially after the 

 providers and allows providers from Massachusetts to provide access to patients in other states.

 decision, there was a contraceptive access law that got passed. It required insurers to cover access to contraception with no cost share. And then immediately after the 

 decision, that same bill had a provision for mandating coverage for abortion and abortion-related care without cost share.

Alice Crisci, co-founder and CEO of Ovum Health, which provides virtual reproductive care in states with and without bans

In the state of Idaho, we have one of the most restrictive laws in America that prevents even a dilation and curettage (D&C) procedure from being performed. If you perform a D&C procedure, even if it’s to save a woman’s life because she had a partial miscarriage, it is a criminal offense, and a physician can lose their medical license.

In some of these really restrictive states, it’s nerve-wracking to deliver care to high-risk patient populations. Ob-gyns are 

 medical professions out there. We’re concerned about medical malpractice rates rising in some of these states where these restrictive laws could cost someone’s life.

 was overturned, I can say that I was terrified, I was disappointed, but I can’t say that I was surprised.

Beverly Gray, ob-gyn at Duke Health in North Carolina, which has a 12-week ban

We’ve had a lot of changes over time in North Carolina. Initially, right after

 that went into place, and so access to reproductive care was dramatically curtailed very quickly. Many of those folks would travel to North Carolina for care. Approximately a year after the 

 decision, North Carolina enacted a very strict abortion ban that has restrictions after 12 weeks, with multiple different layers of exceptions. But there are also many other components of the law that make it very challenging to care for patients day to day, including an in-person, 72-hour biased mandated counseling by the state.

Many patients are traveling, and North Carolina was one of the top four states for receiving travelers for care. Let’s say you needed some type of urgent surgery, and you were told, “Well, no one in your state does this surgery. You need to go to another state. And I’m not going to give you a referral—good luck finding somebody to care for you.” Even for someone who is very well resourced and knowledgeable, that’s a really hard barrier to overcome. Many patients seeking care are receiving Medicaid for their insurance coverage, and Medicaid doesn’t cover [abortion] care, and so they’re paying out of pocket.

How reproductive health has changed 3 years since Roe v. Wade was overturned 

Reproductive health experts share how patients and clinicians are concerned about safety in a post-Roe world. 

In the span of less than five years, providing abortion meds via telehealth has gone from illegal to normal.

By Q2 2024, an estimated 20% of all abortions were facilitated via telehealth, according to an October 

 from the nonprofit Society of Family Planning’s #WeCount initiative. There were 57,150 telehealth abortions in total that quarter, up from 22,430 during the same period a year before.

But this new prescription method is now facing legal threats.

 in January—separately sued New York doctor Margaret Carpenter and her practice Nightingale Medical, accusing the provider and clinic of violating their states’ near-total abortion bans by telehealth prescribing abortion-inducing drugs to patients residing in their states.

The lawsuits are the first major tests of shield laws, which protect abortion providers from out-of-state prosecution or investigations related to their abortion care services.

 that these moves could have a chilling effect on providers’ willingness to offer telehealth abortion care in states where it is illegal. So far, however, experts note that nothing has changed.

“Most providers are standing firm and saying, ‘I’m going to keep doing this as long as I possibly can—until if and when something changes,’” Amy Merrill, co-founder of Plan C, an organization that monitors all the sources of abortion medication available online, told Healthcare Brew.

Plan C has found that online providers don’t seem deterred by the current litigation against shield laws—at least not yet.

Merrill said she knows of at least two online abortion pill services that stopped offering abortion care after the November presidential election—she declined to name which ones—but to her knowledge, none have stopped care after the suits began.

“The fear created by this shifting legal landscape [could] cause providers to just pull out and say, ‘I'm done, even if what I’m doing is totally permissible [in my state],’” Merrill said. “But we haven’t seen a big wave of that.”

Out of the 23 states (including Washington, DC) with reproductive care shield laws, eight, including New York, enacted telemedicine-specific laws to protect providers regardless of patients’ location following the June 2022 

 ruling, according to the University of California, Los Angeles.

Meanwhile, New York Gov. Kathy Hochul is also holding firm. She strengthened the state’s shield law on Feb. 3, removing requirements for providers to put their names on prescription labels. And when Louisiana requested Carpenter’s extradition, Hochul flatly refused on 

But providers still face threats: Those charged with criminal abortion can lose their medical licenses in states without shield laws or be arrested if they travel to a state without them, a 2023 

 in the New England Journal of Medicine noted.

Though not all telehealth abortion services offer care to people living in states where abortion is banned, care via shield laws makes up nearly half of all telehealth abortion care. #WeCount found that from April to June 2024, there were 19,000 telehealth abortions on average per month. Of those, an average of 9,700 were done via shield laws.

Ushma Upadhyay, #WeCount co-chair and University of California, San Francisco professor, told Healthcare Brew it’s not clear how many of the abortions now done via shield laws were done via other methods before.

But she’s confident that shield laws have changed telehealth abortion care for the better.

Prior to these protections, she said, patients in states where abortion was illegal were primarily obtaining pills from European doctors. With thousands of miles between them and their prescriber, it was harder to get questions answered or receive follow-up care. Now, she says it’s much easier.

“Shield law providers…really are providing care that is so essential,” she said. “It takes a really special person to be able to provide care that they could be prosecuted for, and takes a lot of bravery and heroism.”

Shield law challenges have not deterred telehealth abortion, experts say

As legal battles heat up, providers aren’t backing down.

It’s been three months since seven states 

 to add abortion protections to their constitutions, and not as much has changed as clinics had hoped.

In five states that added protections, abortion was already allowed either with no gestational limit or up to fetal viability, which varies by pregnancy but is typically about 24 weeks gestation, according to the American College of Obstetricians and Gynecologists.

In two states, “yes” votes set the stage for potential law reversals: Arizona, where a 15-week ban took effect in September 2022, and Missouri, where a total ban with limited exceptions took effect in June 2022, minutes after the Supreme Court 

The problem is that a state’s constitutional amendment doesn’t automatically override state laws. There are still restrictions in these states and across the nation that impact patient access and threaten clinics’ ability to stay afloat, providers say.

There are still legal technicalities, residual restrictions, and a lack of awareness about the changes, Gabrielle Goodrick, medical director at abortion care clinic Camelback Family Planning in Phoenix, told Healthcare Brew.

“[After the amendment passed], we were on cloud nine,” Goodrick said. “But there’s so many other factors.”

Arizona’s amendment took effect following a statewide canvass on Nov. 25, per the state constitution.

Arizona-based providers then filed a lawsuit on Dec. 3 to overturn the state’s 15-week ban, according to the American Civil Liberties Union (ACLU) of Arizona.

The suit is still ongoing, but the day it was filed, state Attorney General Kris Mayes signed a stipulation that says the 15-week ban is “unconstitutional and unenforceable” while the suit plays out. This allowed providers to resume abortions up to fetal viability or past that point if needed to save the mother’s life.

Goodrick said her clinic immediately resumed abortions past the 15-week threshold. She estimates they do at least a dozen a week for patients from all over the country.

But many patients and even some physicians don’t know that abortions past 15 weeks have resumed, Goodrick said. There are also still other restrictions in effect, like a requirement that makes patients wait 24 hours between their initial consultation and abortion.

It’s a rapidly changing and complicated situation that is straining clinics nationwide, she noted.

“We’re seeing patients from Louisiana. We see Floridians. We see Texans every day. People are trying to get the healthcare they can, and we’re trying to help them,” Goodrick said. “But it’s overwhelming. It’s overwhelming to the system that was already overwhelmed before 

Several states over in Missouri, residents also voted to add abortion protections to the state constitution.

Missouri’s two Planned Parenthood affiliates and the ACLU of Missouri sued the state on Nov. 6 to overturn its abortion ban and other restrictions, such as a 24-hour waiting period requirement that is similar to Arizona’s.

On Dec. 20, the 16th Judicial Circuit Court of Jackson County in Kansas City temporarily blocked some of Missouri’s existing abortion restrictions—including the ban—from being enforced while the case plays out, but it didn’t block them all.

Hospitals are able to resume abortion care, for example, but there are still requirements in place that prevent Planned Parenthood clinics from providing abortion services, such as making abortion clinics obtain a license from the state, according to a Dec. 21 statement from the local ACLU.

“Unless these discriminatory laws are enjoined, Missourians will continue to be denied full access to the abortion care that is now protected under our state constitution,” read a statement provided to Healthcare Brew from the ACLU and Planned Parenthood affiliates.

And then there’s Florida, South Dakota, and Nebraska. These states did not get enough support for amendments to protect access to abortion, leaving restrictions in place for now.

As of Jan. 6, 12 states have near-total abortion bans in effect with limited exceptions, according to the 

 tracker. Seven more ban the procedure between six to 18 weeks gestation.

At least 76 independent clinics, like Goodrick’s, have stopped offering abortions or closed altogether since 2022, according to November data from 

, a national membership and advocacy organization for independent clinics.

Goodrick worries about the financial viability of clinics in other states, but holds on to hope.

“Even not being able to provide care over 15 weeks [gestation] affected our numbers,” she said. “But we survived, and I think in the states where abortion is at least legal for some gestations, they can pivot and provide other care, maybe, and hopefully, things will swing back.”

Abortion protections passed, but clinics still struggle

Arizona and Missouri, in particular, are stuck in a legal tug-of-war over abortion access.

In May 2023, a man drove a car through a future reproductive health clinic in Danville, Illinois. He arrived with bottles of gasoline, a hatchet, road flares, and matches 

 to set it on fire, authorities reported.

While no one was harmed, the clinic, Affirmative Care Solutions, hasn’t been able to open.

Affirmative Care Solutions Director LaDonna Prince said this is just one example of growing hostility toward her shrinking profession.

“It was more than just destroying a building. It took a piece of me away and a piece of the security that I’ve had,” Prince said during a December 3 forum held by Abortion Care Network (ACN), a national membership and advocacy organization for independent clinics not affiliated with a larger company like Planned Parenthood.

ACN’s annual Communities Needs Clinics report, 

, details the harassment, increased administrative burdens, and closures that clinics like Prince’s have faced since the US Supreme Court 

The ACN’s report found that independent abortion providers are an endangered species.

In total, there are 363 brick-and-mortar independent abortion clinics plus 223 online-only clinics across all 50 states, Puerto Rico, and Washington, DC—compared to 510 when the ACN started tracking clinic closures in 2012.

Since 2022, at least 76 independent clinics have stopped offering abortions or closed altogether, including at least 23 in 2023 and 11 in 2024, as of November, according to the report.

Clinics that are still open are struggling to keep the lights on while also maintaining staff amid the job’s difficult work environment, providers said during the forum.

“Most doctors are not willing to do this work due to threats and harassment and intimidations,” Ona Marshall, co-owner of EMW Women’s Surgical Center in Kentucky—which made abortion illegal in 2022—explained.

There are also administrative and legal barriers that make it difficult financially and logistically to stay afloat, she added.

In 2023, nonprofit the Guttmacher Institute reported on state regulations for abortion providers that went “beyond what is necessary to ensure patient safety in the event of an emergency.”

Nine states, for instance, require procedure rooms to be a specific size, and eight states require corridors to be a specific width. Several have “onerous” licensing standards for abortion clinics that are “comparable or equivalent” to those of ambulatory surgical centers, according to Guttmacher’s report.

EMW had a Lexington location that closed in 2017 after a months-long legal battle with then-Governor Matt Bevin’s administration over licensing requirements. (Abortions were legal in Kentucky at that time, with restrictions.)

“There are cycles of winning and losing in these legal challenges, and clinics can be forced to close for a period of time. And for many clinics, when they close, there’s no income,” Marshall said.

The ACN’s report confirmed that while at least 32 new clinics opened between 2022 and November 2024, it wasn’t enough to offset the closures.

This decline is partly a response to state laws following the 

 abortion ban tracker shows 13 states currently ban the procedure with few or no exceptions and seven restrict it to 18 weeks of gestation or earlier. 

But eight of the 11 clinics that axed abortion services in 2024 were in states where the procedure was protected, the report found. That means even clinics in states where abortion is legal face resistance, Prince said during the forum.

“It doesn’t matter if you go into a state where abortion is still legal and welcomed—it just depends on what’s going on in that community. It’s not necessarily just a statewide welcome mat,” she said.

Women wait in the waiting room at Camelback Family Planning, an abortion clinic in Phoenix, Arizona

Report: Independent abortion clinics are struggling to survive

It’s a tough time to run an abortion clinic. 

Report finds independent abortion clinics face more threats, decline post-Dobbs

Seven states succeeded and three failed to pass constitutional amendments to protect abortion access on November 5, according to Associated Press projections.

Many of the states that voted to protect abortion already allow it, either with no gestational limit or up to fetal viability, including Colorado, Maryland, New York, Nevada, and Montana. (Viability varies by pregnancy but is typically around 24 weeks, according to the American College of Obstetricians and Gynecologists.)

But two other states’ yes votes have set the stage for a potential reversal of current laws: Arizona, which currently has a 15-week ban, and Missouri, which enacted a near-total ban in June 2022 just minutes after the Supreme Court turned the decision over to the states in 

Arizona’s amendment is set to take effect following a statewide canvass on November 25, per the state constitution.

Missouri’s amendment is scheduled to take effect on December 5. That doesn’t mean abortion restrictions are automatically repealed, however. Planned Parenthood’s Missouri affiliates are 

 to stop enforcement of the current restrictions and allow three Missouri clinics to resume offering surgical and medication abortion on that date, leaders said in a Wednesday press conference.

“We have the staff and the facilities to do it—we just need the court to understand the urgency and fulfill the will of the voters,” Richard Muniz, interim president and CEO of Planned Parenthood Great Rivers, said during the conference.

This expansion could also lighten the load for nearby states, where Missouri residents currently travel to and “compete with patients from around the country” for abortion appointments, Emily Wales, president and CEO of comprehensive health at Planned Parenthood Great Plains, said during the conference.

Nationwide, abortion restrictions have forced patients to go farther away for care, increased wait times, and strained finances at independent clinics in states both with and without bans, 

Meanwhile, Florida, South Dakota, and Nebraska voted no on amendments to protect abortion, according to voting results posted on the states’ websites, leaving existing abortion bans and restrictions in place.

Some states had ballot initiatives that aimed to restrict rather than protect abortion in the constitution. Nebraska voted yes on an amendment to enshrine the state’s current 12-week abortion cutoff. It is one of two states with an active 12-week ban as of 

, according to the New York Times abortion tracker.

Thirteen states currently ban abortion with very limited exceptions (including Missouri and South Dakota), and four, including Florida, ban it at six weeks with limited exceptions, according to the tracker.

In a statement to Healthcare Brew on Wednesday, Erin Grant, co-executive director of the Abortion Care Network, a membership and advocacy organization for independent clinics, expressed hope for the seven states where amendments passed, but fears for abortion access overall.

“Independent clinics are doing their best to stay open and help their communities. Right now, it is unclear if they will receive relief and help to continue,” Grant wrote.

Hand holding abortion pill over ballot box.