No Choice, No Voice: Combating Abortion Barriers in the U.S.

Natasha Dacic*, Christina Del Greco*, Natalia Harris*, Kelsey Kochan*, Elena Levi-D’Ancona*

*All authors contributed equally.

^Written before the Dobbs v. Jackson Women’s Health Organization (2022) decision.

Featured image credit: Planned Parenthood

Summary:

Hostile Abortion Environments (HAEs) lead to the removal of safe and accessible abortion health care, disproportionately harming low-income and minority individuals. To combat the harsh abortion restrictions within HAEs, we propose local policymakers expand telehealth opportunities and increase dedicated local funding, using Virginia's Henrico County as a model.

Figure 1. Overview of current abortion access restrictions. Our graphic is adapted from a previous study.

Current U.S. Abortion Access Landscape:

The right to abortion is under increasing threat. In 2022 alone, 519 abortion restrictions were introduced in 41 states. Currently, 58% of women live in abortion-restricting states, a 9% increase since 2000.

There are nearly 630,000 abortions performed annually. Abortion restrictions (Figure 2) have closed clinics and forced patients to travel farther to receive care. This burdens abortion patients, 75% of which are from marginalized communities (low-income, minority groups) and/or facing significant financial barriers to accessing care. Abortion programs strive to protect abortion access in hostile abortion environments (HAEs) via covering medical expenses, childcare, and patient travel, but available funds are severely limited. There is a clear need for expanding funding and other methods to improve access to abortion, particularly in marginalized communities hit hardest.

Figure 2. States were scored from 5 to -5, -5 indicating the highest restrictions. Negative points were assigned for abortion restrictions, and positive points were added for abortion protections available in each state. Our analysis is adapted from a previous study.

Approach 1: Funding for Abortion Services at the Local Level

The Hyde Amendment prohibits federal funds from covering abortion services. Therefore, states and cities have a legislative and financial role in increasing access to abortion and reproductive services.

Cities have created municipal funding streams for abortion and reproductive health care:

• In 2019, New York City budgeted $250,000 for the New York Abortion Access Fund (NYAAF), making it the first city to directly allocate abortion funds.
• ~⅓ of the people NYAAF supported in 2019 were from out-of-state due to increasing state restrictions for abortion services.
• Austin set aside $150,000 to support travel and child care expenses for those seeking abortions.

Abortion access/restriction extends beyond state residency:

• California and Connecticut are the only states considering bills to protect abortion providers from lawsuits filed by states where abortion is illegal.
• A Missouri bill proposed this year would make it illegal for a Missouri resident to seek an abortion out-of-state.

Increasing local funding towards abortion healthcare is one method that can be implemented to broaden abortion access for individuals in marginalized communities.

Approach 2: Increasing Abortion Access with Telehealth

Telehealth, a virtual healthcare service that reimagines the traditional clinic-based service, expands access to abortion-related healthcare.

Figure 3. Telehealth abortion statistics. Hyperlinks associated with our original graphic from left to right: 41%, 76%, 94%.

Telehealth services can connect clinics lacking abortion services to clinics that have them, particularly in HAEs:

• Women living below the poverty line are 20% more likely to seek out telehealth abortion services.
• TeleMAB increased the number of medicated abortions and decreased the overall distance traveled to obtain abortions.
• Telehealth abortion services are as effective as in-person services concerning medicated abortion, provide a safe alternative to in-person visits, and can increase abortion access to disadvantaged communities.
• Planned Parenthood’s (PP) teleMAB trial and the TelAbortion Project both use “site-to-site telemedicine for medication abortion” to link health centers together via videoconferencing.
• PP provided over 350,000 telehealth appointments from April to September of 2020.
• 56% of PP clinics are located in rural or marginalized communities, and 35% of PP patients are people of color.

This could be used as a model for women’s health centers to broaden access beyond PP, particularly for individuals in marginalized communities.

Implementing Our Approaches via Recommendations:

The lack of funding and access to abortion care results in negative health and financial outcomes, particularly in marginalized communities within HAEs. Repealing the Hyde Amendment would increase in-person abortion access for patients covered by Medicaid, but we do not see this as a feasible policy recommendation. Instead, we recommend creating abortion havens by focusing policy interventions on regions within HAEs that support abortion access.

For example, we propose targeting Virginia’s Henrico County, which supports abortion access despite the state’s anti-abortion laws. Two recommendations could be extrapolated to other receptive counties within HAEs, including other counties in states lacking restrictions on telehealth such as those in Georgia, Ohio, and Pennsylvania:

Approach 1. Policymakers should dedicate local funding to abortion programs and reproductive health clinics. Henrico County houses several reproductive justice programs, such as the Richmond Reproductive Freedom Project and the Blue Ridge Abortion Fund. These programs cover costs of abortion procedures, clinic visits, and travel expenses for low-income patients. They allow people with Medicaid, which cannot cover abortion procedures under the Hyde Amendment, to receive healthcare funding at local clinics.

Approach 2. Policymakers and healthcare professionals should expand telehealth opportunities for increased access to reproductive care in rural areas. Local policymakers and clinics could provide more comprehensive reproductive telehealth outreach for individuals in rural and low-income areas. Expanding telehealth will allow pregnant people greater access to information about reproductive health care and medicated abortion options. Telehealth is already a feasible option for individuals unable to access abortion clinics, as there is no additional cost.

Limitations:

The recommendation to increase telehealth access cannot be extrapolated to all HAEs. Some HAEs ban the use of telehealth for abortions. For instance, in Texas, while telehealth does not increase abortion access, expanding these services increases the dissemination of information regarding reproductive health care. In these states, we recommend funding abortion access programs in supportive cities and grassroots efforts to loosen future telehealth restrictions.

Addendum: In light of the recent Supreme Court decision, identifying approaches such as these (and others) to expand abortion access at the local level is increasingly urgent.