Memo: How Blue States and Cities Can Expand Abortion Access
By Arielle Swernoff
Introduction
History and Context
Across the country, restrictions on abortion are snowballing. Since 2010, states have passed nearly 500 laws curtailing abortion access — from TRAP laws creating arbitrary and expensive building guidelines for providers, to mandatory waiting periods, compulsory “counseling” (often including misinformation) for patients, and more. Until 2016, abortion restrictions were limited to individual states, but during his tenure, President Trump appointed three conservative, anti-choice Supreme Court justices, setting the stage for federal action to restrict abortion. Two recent laws have given the Supreme Court the opportunity to adjudicate abortion rights in the United State: Texas’s SB 8, which bans abortion after six weeks, forcing pregnant people in the state to travel vast distances to clinics out of state; and Mississippi’s 15-week abortion ban, currently under review in Dobbs v. Jackson Women's Health Organization.
Roe v. Wade, the landmark Supreme Court case enshrining a consitutional right to abortion pre-viability (a term that’s challenging to define, and one of several reasons why activists consider Roe to be a compromise to begin with) is at risk of being overturned. If this happens, dozens of conservative states will work to swiftly ban abortion, leaving millions of Americans without easy access to necessary abortion care. People of color, trans and queer people, poor people, people who lack citizenship, people living in rural areas, and others already marginalized by our social and economic systems will experience the worst impacts.
When people are unable to access abortion care in their communities, three things can happen. First, people will have to save and spend sometimes thousands of dollars to travel across state lines for necessary health care — not to mention the cost of child care, time off of work, and other risks they might incur (including crossing border checkpoints). Or, they will be forced to carry unwanted pregnancies to term, which can have serious consequences. According to UCSF’s groundbreaking Turnaway Study, people denied abortion care who went on to give birth experienced increased poverty, lack of resources for basic living expenses, and greater likelihood that they would still be in contact with a violent partner than those who recieved a wanted abortion. Finally, some people will attempt to self-manage abortion — which can be done safely and effectively — but remains expensive and carries some legal risks.
National reproductive health and justice groups lost ground over the past ten years. Well-resourced, major national organizations likeNARAL Pro-Choice America have disinvested in state and regional organizing, effectively ceding powere. Instead, they have chosen to focus on the courts, which are structurally biased toward conservatives and leave little room for building mass movements.
Why State and Local Policy
The anti-choice movement has been fighting at the state and local level to curtail access; the movement for abortion access and reproductive freedom must do the same. In conservative states, that responsibility has fallen to grassroots organizations, which have worked to push back against regressive policies and provide meaningful support to pregnant and parenting people. Because they operate in hostile territory and with limited resources, their work must be supported. As more abortion restrictions are passed, people will continue to travel vast distances to obtain abortion care. Liberal states can step up to make abortion accessible, affordable, and dignified within their borders—both for out-of-state travelers looking for abortion care, and for residents who already live there. Not only will these changes improve the lives of people who need abortion care, they have the potential to become blueprints for federal law, increasing access to abortion nationwide. This policy memo outlines several ways that liberal states and cities can expand abortion access.
Other Work
This memo is not comprehensive, and includes only some of the many available policy avenues to expand abortion access. For example, the memo does not include policies to ensure abortion is available at public hospitals, encourage training new abortion providers, or expand telemedicine services. There is always more work to be done.
Additionally, abortion is inextricable from issues of racial and economic justice. Organizations such as SisterSong promote a framework of reproductive justice that centers access to abortion in addition to personal choice. Traditional pro-choice movements rest on the notion that people should be able to decide whether to continue their own pregnancy. But if they lack the time, money, and support to follow through — either with the decision to abort, or to parent a child — that “choice” is no choice at all.
The reproductive justice framework also encourages us to center the most marginalized communities. Indigenous people and people of color are most severely impacted by abortion restrictions, and also have difficulty accessing contraception, comprehensive sex eductation, STI prevention and care, adequate birth options, prenatal, and pregnancy care, domestic violence support resources, good wages, safe homes, and more.
Policy is not the only path forward: grassroots organizing and mutual aid will always be a necessary component of achieving reproductive freedom and justice. Community support for abortion funds remains critical, as are campaigns to de-stigmatize self-managed abortion and make abortion pills available to all.
Policy Mechanisms
Expand health insurance coverage of abortion
The Hyde Amendment prohibits federal funds from being used to cover abortion, effectively banning it from all federal health insurance plans—meaning that people on Medicaid, members of the military, federal employees and their dependents, Peace Corps volunteers, incarcerated people, people recieving health care through the Bureau of Indian Affairs, and others are unable to access insurance coverage of abortion. In addition, many states bar state-level public sector health plans and plans purchased on the Affordable Care Act marketplace from covering abortion. When people on federal health insurance plans (or in many cases, state public plans or marketplace plans) need abortions, they are forced to pay out of pocket. Because 85% of Medicaid recipients identify as non-white, these restrictions disproportionately harm abortion seekers who are people of color.
A number of factors influence the cost of abortion, but in 2018, the mean cost of a medication abortion was $535, aspiration abortion ranged from $435 - $955, and a D&E abortion ranged from $500 - $3,000. Medication abortions, which are performed up to ten weeks following a person’s last period, involve taking two kinds of pills that induce cramping and bleeding to empty a person’s uterus. Suction abortion, or vacuum aspiration, is performed in-clinic, where a medical professional will use gentle suction to empty the uterus, and can be performed up to 14-16 weeks following a person’s last period. D&E stands for dilation and evacuation, in which a medical provider uses suction and medical tools to empty a person’s uterus. It can be performed later than aspiration, usually if it’s been 16 weeks or longer than a person’s last period.
There are many reasons why a person might get one type of procedure rather than another beyond the timing of the pregnancy — the need for flexibility (with medication), preferring to have the support of medical staff (aspiration), or having certain underlying medical conditions making one or another option a better choice.
What’s clear is that any type of abortion is expensive. Given that in January 2020, only 41% of Americans would be able to cover the cost of a $1,000 emergency from savings, the lack of insurance coverage for abortion care has dire financial consequences. The Hyde Amendment and related restrictions disproportionately harm low-income people, people of color, non-citizens, and others who are already marginalized and would have difficulty paying for an out-of-pocket abortion.
Sixteen states provide funds to make up for this lack of federal investment, providing dollars from their own state budgets to cover abortion for Medicaid patients. Many others allow abortion coverage in ACA marketplace plans, and include it in health plans for public sector employees. However, five states that boast Democratic trifectas still do not make up the funds to include abortion care for Medicaid recipients, and others do not allow abortion coverage for health plans purchased on the ACA marketplace, or bar state-level public sector health plans from covering abortion.
Beyond expanding public sector coverage, some states, such as New York, have the opportunity to go further: making up the Medicaid funding gap still wouldn’t protect everyone, and there will still be pregnant people who are uninsured, underinsured, or on private health plans that don’t cover abortion. Passing universal health care policies like the New York Health Act could help make abortion accessible to all.
Direct resources to abortion funds, community health providers, and sexual and reproductive health clinics
Both states and cities have a role to play in increasing abortion access, through legislative means and through their budgets. States and municipalities can not only direct money to abortion funds and practical support funds to directly support abortion access; they can also fund community health centers, sexual and reproductive health care, contraceptive services, doulas, diapers, and formula as part of a broader effort to ensure people have access to dignified support and services throughout their reproductive lives. Two cities—Austinand New York City—have created municipal funding streams for abortion and other reproductive health care, providing examples for other cities to follow suit.
In 2019, New York City included $250,000 in its budget for the New York Abortion Access Fund (NYAAF), a group that helps people seeking abortions cover the cost of their procedures. This was the first time a city has directly allocated money to an abortion fund. This support has been and will continue to be critical not just for New Yorkers, but for hundreds of people who travel from out of state to terminate their pregnancies in New York. According to NYAAF, roughly one-third of the people they supported in 2019 came from out of state, a figure that is likely to increase as other states crack down on abortion access.
After Texas barred local governments from providing funding to abortion providers, the city of Austin set aside $150,000 to support abortion-seekers in paying for travel expenses, lodging, and child care. Often, the cost of the medical procedure is only one of many burdens abortion seekers face: as clinics close, many people have to travel, stay overnight in hotels or motels, and find child care in order to receive an abortion. Mandatory waiting periods increase these costs. People may also require additional supports, such as translation services or abortion doulas. This category of funding is known as practical support and it’s an option for states and cities to seeking to improve abortion access.
The Texas Equal Access Fund, an abortion fund in North Texas, finds that 70% of funding recipients are people of color. Thus, abortion and practical support funds provide critical resources to abortion seekers of color who, because of centuries of racist policy, are less likely to have access to the material resources necessary to get an abortion in a hostile climate. .
Critically, states and municipalities should fund not just abortion care but practical support and other sexual and reproductive health services, including contraceptive services, doulas, diapers, hormone replacement therapy, and more.
Allow all qualified medical professionals to provide abortion care
Thirty-six states require abortions be provided by a licensed physician and do not allow other qualified medical professionals, such as physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs), to perform the procedure. PAs, NPS, and CNMs all fall under the category of advanced practice clinicians — highly educated and trained health care providers who often deliver significant amounts of primary care. In many cases, advanced practice clinicians can write prescriptions, give diagnoses, and are often a patient’s main contact in their health care system. Studies show that first trimester abortions are just as safe when performed by trained NPs, PAs, and CNMs as when conducted by physicians.
Restricting abortion provision to physicians creates significant, often arbitrary barriers for people seeking abortion. Primary care clinicians — including family medicine doctors, physician assistants, nurse practitioners, and certified nurse midwives — are much more likely to serve patients at risk for unintended pregnancy than OB-GYNs. Due to a shortage of doctors practicing in rural areas, in many counties, advanced practice clinicians are the main or even only health care providers. Even in major cities, for many Americans who have a primary care provider, that person is not a doctor, but a nurse practitioner or physician assistant working in concert with a clinical team. People may feel safer and more comfortable if their abortion could be performed by a medical professional with whom they have an existing, trusting relationship.
Recently, several states have changed regulations to allow advanced practice clinicians to provide abortion care. In 2019, Maine changed its laws to allow NPs, PAs, and other qualified medical professionals to provide abortion, a move that’s had a significant impact on people living in rural parts of the state. Prior to the 2019 law, Maine only had three clinics, each in a major city, where doctors provided abortion care once per week. Allowing advance practice clinicians to provide care has made abortion more available and accessible to rural Mainers.
Hawaii changed its laws in April 2021 to allow advanced practice clinicians to provide medication and aspiration abortion. Prior to the passage of this law, the islands of Kauai, Molokai, and Lanai lacked local abortion care providers, forcing patients to fly to larger cities to obtain care. For years, the 168,000 residents of Maui only had access to abortion through a physician that flew in twice per month, a practice that was suspended early in the pandemic — effectively halting abortions on the island.
Most recently, in October 2021, New Jersey also changed the law to allow advanced practice clinicians to perform abortion, widening the pool of potential providers by thousands. There is significant momentum behind this shift.
Crack down on crisis pregnancy centers
Crisis pregnancy centers (CPCs) are fake clinics which advertise themselves as centers to support people experiencing unintended pregnancies; their intent is to prevent people from getting abortion care. They often mimic the names, signage, and web presence of local abortion clinics, often renting space in the same block or building, and in one case, using the phone number and office of an abortion clinic that had been shuttered. In their attempt to steer people away from abortion, crisis pregnancy center staff make false and debunked claims linking abortion to increased risk of breast cancer or psychological trauma. Staff also misrepresent themselves as medical professionals, wearing white coats or referring to themselves as counselors, even when they are not nurses or doctors and lack any medical training. In particular, crisis pregnancy centers have instituted programs focused on recruiting women of color, especially in areas that are underserved by quality medical services.
As of 2012, an estimated 2,500 - 4,000 crisis pregnancy centers operate in the United States, compared to 1,587 abortion clinics.
Crisis pregnancy centers are notoriously difficult to regulate, as attempts at requiring disclosures and limiting the spreading of misinformation have faced First Amendment court challenges. However, cities and states have pursued some methods: Austin, Texas, San Francisco, California and other localities have passed laws requiring clinics to disclose when they are not licensed medical facilities. New York City and Oakland, California have gone further, levying fines on centers that have failed to make these disclosures. Many of these disclosure regulations have faced challenges — either from the courts or from CPCs avoiding compliance — and there is significantly more work for policy leaders to do to address the harms caused by CPCs.
Additional options could include restricting the funding of crisis pregnancy centers. In many conservative states, CPCs receive funds pulled from state TANF grants. TANF — or Temporary Assistance for Needy Families — is a program to assist low-income families and children. States such as Ohio direct TANF federal funds to crisis pregnancy centers; legislatures can work to stop this diversion of necessary welfare funds. Municipalities can also enact policies barring contracts with crisis pregnancy centers, as is the case in Dane County, Wisconsin.
Finally, crisis pregnancy centers attract desperate people because they offer free or discounted sonograms, “counseling”, and baby supplies, such as formula and diapers, often in exchange for attending parenting classes and workshops that typically have a strong Christian focus. A stronger social safety net, which would include free health care (including mental health care), and other support for new parents (including free supplies) would seriously curtail the power of CPCs.
Remove gestational age limits on abortions
There are many reasons why a person might need an abortion later in their pregnancy: they may have had difficulty saving money or finding a clinic, be living in an abusive or coercive household, may not have known they were pregnant, have received new information about a potential health complication, or a variety of other reasons. However, only eight states and districts currently have no gestational age restrictions on abortion: Alaska, Colorado, New Hampshire, New Jersey, New Mexico, Oregon, Vermont, and Washington, DC.
While abortions after 21 weeks are rare, accounting for just over one percent of all procedures, they do happen, and gestational age restrictions can create undue burdens. Such was the case of Erika Christensen*, who learned 31 weeks into her pregnancy that her baby would not be able to breathe. At the time, abortions after 24 weeks were not allowed in her home state of New York. She had to fly to Colorado to receive the first part of her procedure, then fly back to New York to labor and deliver, an extended and expensive process that also proved to be traumatizing for her and her family.
Christensen was part of the campaign to pass New York’s Reproductive Health Act (RHA) in 2019, which, among other things, allowed abortions in-state after 24 weeks if the fetus is not viable or the health of the pregnant parent is at risk. While the RHA represents a step forward, many people seeking later abortions are still left out. A person who needs an abortion later in their pregnancy because they couldn’t save the money, didn’t know they were pregnant, or are experiencing domestic abuse, substance abuse, or mental illness, would still be excluded. Oregon and Vermont both have laws prohibiting government interference at any stage of pregnancy; other states could affirm people’s dignity and ability to know what is right and moral by following suit.
*Christensen had her name changed for this interview. She later chose to share her identity, and has advocated for removing restrictions on abortion later in pregnancy.
Conclusion
The fight for abortion access is at a critical juncture. The Supreme Court is currently hearing arguments on Dobbs v. Jackson Women's Health Organization, and could conceivably overturn the constitutional right to an abortion in the United States. The consequences of this would be devastating: dozens of states are expected to ban abortion, and poor people, queer and trans people, people of color, immigrants, young people, people living in rural areas, and others lacking in resources and facing marginalization will be hit first and worst.
When faced with an unwanted pregnancy, people living in abortion ban states will either undergo the medical risk and potential trauma of carrying an unwanted pregnancy to term; manage their abortion at home, which, while safe, can carry legal risk and remains expensive; or be forced to put together money they don’t have, time off they can’t get, and child care they can’t afford to travel hundreds or thousands of miles for abortion care.
There is so much work to be done to protect and expand abortion access. Rather than adjudicating at the Supreme Court, we can shift our focus to state and local work that protects those most hurt by abortion bans and expands access for all. We must continue to support independent abortion clinics, abortion funds, and grassroots groups operating in hostile territory, and expand access everywhere we can.
Liberal states and cities have an important role to play: by making abortion care more accessible, they can ease the burden of abortion travelers coming from more hostile environments, and can make abortion easier to obtain for their own residents. And the policies enacted today can provide a blueprint for the future. This must also be part of a larger, broader strategy for the left to gain power across the country — winning in state legislatures, city councils, and at the federal level, and investing in grassroots infrastructure to sustain those wins.
We must continue to support the work of activists on the ground, expand access where we can, and never let up the fight for abortion justice.
Arielle Swernoff (@ArielleSchw) is an organizer and strategist living in New York City. She currently works for a climate justice coalition, and has previously worked to elect progressive candidates to state and local office, for the New York City Council, and in adolescent health communications.