Originally published in Vox on June 14, 2022.
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When Susan Brewer’s wife lost her job during the pandemic, her family, living on the South Side of Chicago, fell behind on rent. Brewer had been supplementing her wife’s salary with the disability income she received from Social Security, but on its own it wasn’t enough to pay their bills.

In December 2021, Chicago opened up a new round of applications for renters needing emergency aid. But Brewer’s landlord — who was then threatening them with eviction —wasn’t interested. Normally, that would have been the end of it: If a landlord refuses to participate in a government program, their tenants won’t get help. But in this case, Brewer was able to apply for and receive the money directly. She picked up her check from City Hall, paid off all her outstanding rental debt, and her wife eventually got her job back.

“Becoming homeless was one of my greatest fears,” she recalled. “I’m 64 years old. I can’t be out in the streets. I’m still struggling to get the weight back I lost from all that stress.”

Brewer was able to stay in her home because, about a year before she got her aid, the federal government had taken an unprecedented step: It decided to help people at risk of eviction stay in their homes. The Emergency Rental Assistance Program — or ERAP — marked a fundamental departure from virtually all previous housing aid programs. Tenants could get money directly, the eligibility process was streamlined, and the categories of people who qualified were intentionally broad.

Nearly 1 million people are evicted in the US each year, mostly for nonpayment of rent. Between 2000 and 2016, according to the Eviction Lab at Princeton University, one in 40 American renter households was evicted, and more than twice that share were threatened with it. The experience of losing one’s home to eviction has been linked to all sorts of adverse consequences, including higher job loss, debt, suicide, and reduced credit access.

Many evicted families are forced to relocate to lower-quality homes in neighborhoods with more crime. Evicted children experience higher food insecurity and lower academic achievement than other low-income kids living in rental housing, partly as a result of having to shuffle between schools and their parents’ declining mental health.

But even as research mounted on the prevalence and harms of eviction, the federal government did little to help families avoid it. “Before the pandemic, evictions were happening and there was a crisis, but we weren’t thinking about federal intervention in that space in a real way,” acknowledged Peggy Bailey, the senior adviser on rental assistance at the US Department of Housing and Urban Development. The federal government would sometimes take action if the eviction violated the Fair Housing Act, but not otherwise.

The situation changed only when the pandemic hit, and orders to “stay at home” grew louder and more urgent. You can’t stay at home if you lose your home.

Initially plagued by bureaucratic hurdles, the rental assistance program eventually succeeded in reducing evictions. Although twice as many renters reported being behind on rent in mid-2021 compared to pre-pandemic times, eviction levels remained well below historic averages by the end of the year. They did not rebound to expected levels even after the Supreme Court struck down the CDC’s federal eviction moratorium. The money also largely reached the vulnerable tenants it was intended to help. Among those renters, researchers have found, the experiment was associated with a host of benefits, including less debt and physical stress.

But now, as federal ERAP dollars dry up, evictions are beginning to climb again.

The country faces a pivotal choice to build on what communities have learned. Before the pandemic, almost 8 million renters spent more than half of their incomes on housing. With more funding, the government could create a permanent program to help those who, living paycheck to paycheck, might need emergency assistance to cover temporary shortfalls on rent. A bipartisan bill in the Senate would do just that.

“What we know now from ERAP is that we can play a role in preventing evictions due to nonpayment of rent,” Bailey said. “Just a little bit of housing assistance can go a long way to saving money and a lot of aggravation for families.”

“We put a lot of effort into building the [rental assistance] plane while we were flying,” added Dave Thomas, the president of the Philadelphia Housing Development Corporation. “And now that it’s built, we have to figure out: Does it last, or was it a lot of energy for nothing?”

The federal CARES Act from March 2020 included money that states and cities could use to assist renters. But it was in December 2020 that Congress authorized $25 billion for its first initiative dedicated exclusively to helping renters stay in their homes. A second round of funding in March 2021 brought Congress’s total ERAP spending to $46.5 billion.

The money was directed to states and localities to distribute to newly created rental assistance programs. These built-from-scratch, decentralized programs, which number over 500 today, had varying rules and requirements for tenants and landlords to apply. Natasha Leonard, a housing specialist with the National League of Cities, said much of her work during the pandemic was spent trying to spread awareness about what other cities were doing for rental assistance. For months, the program was blasted for administrative hangups, shifting and confusing guidelines, and sending money to renters too slowly.

ERAP was administered by the Treasury Department, not the Department of Housing and Urban Development. HUD has more experience developing targeted funding formulas, but Treasury has experience sending money out quickly. It also exists outside of the traditional federal housing bureaucracy, so some leaders felt it was better positioned to innovate and take risks.

Over time, Treasury did innovate. It loosened ERAP rules and clarified its expectations. Jurisdictions scrambled for new technology and staff and for nonprofit partners to help spread awareness among eligible renters.

In 2021, 3.8 million payments were distributed to eligible households. By April of this year, per a Treasury spokesperson, that number had reached 5.7 million. In all, more than $30 billion in assistance has been distributed or obligated, and the remaining money is expected to be spent in the next few months. Activists and reporters are now warning of the funds running out too quickly.

Researchers have found that, by and large, the funds went primarily to communities hit hardest by the economic impacts of the pandemic — places with steeper job losses, higher shares of renter households, and more residents of color. Treasury data published in late February reported that over 80 percent of program funds went to very low-income households, defined as those earning 50 percent or less of area median income, and primarily reached Black, Latino, and female-headed households.

“It was unlike anything — and at a scale unlike anything — we’ve seen in our lifetime,” said Greg Heller, a former Philadelphia Housing Development Corporation official who helped lead the aid distribution for his city.

Claudia Aiken, a policy researcher at the University of Pennsylvania, has already found clear results from Philadelphia. Receiving emergency rental assistance was associated with a lower likelihood of incurring debt, a lower share of tenants reporting that they worried frequently, and a significant decrease in the amount of rent owed among those behind on payments. Other studies on preliminary impacts in Atlanta and Baltimore have found receiving rental aid is associated with reduced risk of homelessness and lower debt.

As states and cities cobbled together their rental assistance programs, policymakers quickly ran into several issues. Landlords weren’t always eager to participate because accepting the money sometimes came with requirements to forgive past penalties, interest, and court costs; or because participating barred landlords from chasing payments for anything outstanding in the months they received aid. Some states capped available rental assistance so low that many landlords saw accepting it as consenting to de facto rent cancellation while they were dealing with their own cash flow problems.

Some programs tried to grease the wheels to induce more participation. A Pennsylvania rental assistance program in place before ERAP launched had a monthly cap of $750, regardless of what rent was owed. But only 44 percent of landlords participated, so Philadelphia policymakers decided to pair state aid with CARES money to offer landlords up to $1,500 per month. This boosted Philadelphia participation to 63 percent.

Still, many landlords just wouldn’t bite. In a national survey of rental assistance programs conducted in spring 2021, 44 percent of program administrators said landlord responsiveness was a challenge. That number rose to 67 percent in summer 2021, and 74 percent in late 2021. As one ERAP administrator explained, “many landlords are not looking to keep unreliable tenants; some refuse to work with us; [and] others are not willing to renew leases.”

Landlord resistance is nothing new in federal housing policy. But to address the issue, Treasury took an unprecedented step. It said that programs must send money directly to tenants when their landlords don’t cooperate, and clarified that programs can even provide direct assistance to tenants before trying to engage the landlord. Not all programs embraced the idea, but many did.

“ERAP operated under the idea that we should help everyone who has a need, and that’s just a radical departure and mindset from our other existing housing programs,” said Aiken.

ERAP’s goal to assist needy tenants was so explicit, and so unlike any past federal program, that Treasury officials even clarified that aid should be delivered to anyone experiencing hardship during the pandemic, not just due to Covid-19.

Federal policymakers have contemplated the idea of distributing rent money directly to tenants, but they’ve only really tried it once before, via a small program that ran in a dozen cities in the 1970s.

“Tenants are the program’s primary beneficiaries,” explained Noel Poyo, the deputy assistant secretary for community economic development at Treasury, who led the department’s implementation of ERAP. “It is a low-income household that meets these tests. The program doesn’t exclude tenants with landlords who don’t want to participate.”

Another defining characteristic of the program was its gradual embrace of unusual strategies to get money out the door. In distributing public funds, governments have an obligation to ensure that the dollars really get to those who need them. But fraud mitigation can go too far, requiring so many bureaucratic hurdles that the aid never reaches those it was meant to help.

Some ERAP programs took dramatic steps to cut down on paperwork. Instead of submitting official records, people could simply affirm, under penalty of perjury, details of their personal circumstances, like their income or address. Administrators were also allowed to verify income by cross-referencing applicants’ statements with other population-level data in the same geographic region.

Others embraced “categorical eligibility”: the idea that if you qualify for one existing welfare program, and that program verified your personal details, then you should be considered automatically eligible for another. Researchers found that programs with fewer and more flexible requirements were able to distribute their rental assistance funds faster.

Watchdogs have thus far produced little evidence of fraud. Eight months into California’s pandemic rental assistance program, housing officials identified 1,800 fraudulent applications out of nearly 500,000 — or 0.0036 percent — and none of those applications were paid. California officials explained they had learned a lot about detecting fraud after the state’s costly unemployment fraud debacle. Other states that disclosed data — such as Utah, Arizona, and New York — reported virtually no rental assistance abuse, either. In Montgomery County, Maryland, auditors wrote in October, “We ultimately found no specific instances of fraud,” though they acknowledged that self-attestation made it difficult for them to discern who might be lying.

In February, federal auditors with the Government Accountability Office warned Congress that they did not think Treasury had implemented enough monitoring controls for its ERAP program, and stressed fraud was a risk. A spokesperson for Treasury said all ERAP grantees must have in place procedures to prevent, investigate, and address fraud. Rich Delmar, deputy inspector general of the Department of the Treasury, the division responsible for oversight, could not provide specifics on ERAP fraud allegations, but said when they receive tips of abuse through their hotline, they investigate them.

Even with Treasury’s encouragement, some local administrators resisted easing up on their program requirements, fearful of the potential for scandal or backlash.

But Poyo, from Treasury, said that ERAP demonstrated governments could reduce unnecessary barriers to aid while still using identity verification tools to evaluate applications. “It is not a zero-sum game between supporting access for vulnerable populations and ensuring strong program integrity,” he said.

ERAP was clunky at times. Local program leaders said the continually shifting Treasury guidance made distributing money more challenging, as did the IT demands and lack of qualified staff and volunteers. It took time to build up coordination with local court systems that handled evictions, too.

“There was a perception at first that if you just dump loads and loads of money that local governments should have some way of getting it out,” said Heller. “But to get hundreds of millions of dollars — in Philadelphia, we had over $250 million — requires a huge amount of infrastructure, a lot of IT backbone, a lot of training.”

While the program overall did a good job reaching needy areas, some struggled more than others. Elizabeth Kneebone, the research director for the Terner Center for Housing Innovation at UC Berkeley, has been studying communities that were more readily able to deploy this federal assistance, which tended to be denser urban areas. Suburbs and rural communities — with fewer nonprofits, diminished or nonexistent local media, and less institutional capacity in their local governments — tended to have a harder time, even as the need for help persisted.

“With the suburbanization of poverty, we need to ask, how do we make these areas more flexible and responsive to the ways needs can change?” Kneebone said.

Experts and policymakers say they are not exactly sure what happens now. Federal funds are drying up and most programs are no longer accepting new applicants. Researchers are continuing to publish new reports on ERAP lessons learned.

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There is a consensus among housing leaders that the next year will be critical in determining whether all this pandemic-era knowledge is sustained and expanded upon, or buried and forgotten.

The National Low Income Housing Coalition, an advocacy group, is focusing on rising eviction rates and the need to establish a permanent emergency rental assistance program, said Sarah Gallagher, the group’s senior project director. “We need it both for individuals in emergency situations because of personal crisis, as well as to prepare for another pandemic,” she said.

If Congress was planning to reallocate new dollars, then local officials would work to invest in infrastructure and staff, just like they do for other permanent housing programs. But at this point, communities don’t know if they’ll be using their ERAP systems again, or be forced to dismantle them.

Meanwhile, HUD is now considering an eviction prevention strategy and is beginning to think through how to start tracking eviction data nationally. In recent federal appropriations acts, Congress tasked the housing agency with considering the feasibility of developing some sort of national eviction database, and three bills have been introduced to increase federal analysis of evictions.

“I think you can make an extremely strong defense that investing in eviction prevention provides a positive economic and social return to the country,” said Gene Sperling, the American Rescue Plan coordinator for the Biden administration. “So even on that hard-headed basis, eviction strategy is the type of wise investment that people think of like quality preschool — especially when you consider the economic scarring, emotional trauma, and heartbreak these policies can prevent.”

The uncertainty surrounding future funding makes this all particularly confusing for local housing leaders. Right now, some communities are still distributing their ERAP funding, which doesn’t expire until September 2025. Localities are also tapping into remaining state and local recovery funds to help sustain their programs.

But these funding streams will, eventually, be gone. On the congressional level, there’s a bill to establish a permanent Emergency Assistance Program. While its proposed $3 billion in annual funding is fairly low, housing advocates say passing the legislation would be an important seed that could help motivate HUD to continue building on ERAP lessons. For now, though, passage looks unlikely.

In the meantime, activists are fighting to press for broader reforms to the housing market.

Gallagher suggested making ERAP recipients automatically eligible for other programs through categorical eligibility. “Some of the households that received ERAP are in need of longer-term subsidies, and now that households have been engaged, we don’t just want to walk away,” she said. “We’ve already deemed them eligible, there should be a way to transition those folks to additional resources, using self-attestation.”

Bailey, from HUD, noted it was her agency that first encouraged Treasury to consider self-attestation as a strategy because HUD knew from experience how hard it can be for homeless populations to receive government assistance when they lack certain documents. She acknowledged, though, that currently no HUD programs, including even its own homeless assistance programs, allow for that flexibility.

Some communities, like Philadelphia and Chicago, have used their ERAP dollars to bolster adjacent housing assistance efforts, like expanding access to lawyers for low-income tenants and encouraging alternatives to eviction through so-called court diversion programs. The White House is encouraging these kinds of efforts and held a summit on court diversion in the summer of 2021, something Sperling said was done partly to accelerate a conversation around long-term eviction reform.

While federal funds certainly enabled Philadelphia and Chicago to run more successful diversion programs (landlords are much more likely to agree to an eviction alternative if there is money available to pay them rent) local leaders say they don’t plan to abandon their diversion efforts even if ERAP dollars dry up. “As our resources have diminished, we’ve tried to be a little more intentional … and do a little more targeting,” said Thomas, of the Philadelphia Housing Development Corporation.

“We used $8 million of our ERAP funds to launch a right-to-counsel pilot because we want this to be not a one-time emergency measure, but to help create infrastructure that can be lasting,” said Daniel Kay Hertz, the director of policy with the Chicago Department of Housing.

“The primary crisis we have now is how many people continue to need assistance, and not having enough money for them,” he added. “But the secondary crisis is that Chicago and dozens or hundreds of jurisdictions gained an enormous amount of administrative capacity to do a direct relief program, and we aren’t sure yet what that will mean.”

Originally published in Suffolk University Magazine‘s spring 2022 issue.

When Boston’s new mayor Michelle Wu announced in early December her decision to move people living in tent encampments at the intersection of Massachusetts Avenue and Melnea Cass Boulevard into nearby transitional housing, she stressed the city would deploy a “public health and housing-first approach.” The goal: Develop a sustainable strategy so that those living in tents would no longer need to return. As many as 140 people were living in the encampment, most of them contending with addiction, mental illness, or both.

Over the next few weeks, city teams vacated individuals from the area—an effort blasted by some homeless advocates as intimidating and reckless, and praised by others who felt the city had to take humane action before winter arrived. Meanwhile, an interdisciplinary team of Suffolk University faculty—all women, and experts in law, policy, sociology, criminal justice, and related disciplines—and several likeminded researchers and social workers were following the mayor’s moves closely. The group had first joined forces in early 2021 under the banner of the Women and Incarceration Project (WIP) to oppose construction of a new women’s prison in Massachusetts. This time, the group came out in support of Wu’s Mass and Cass plan, as the first of many steps needed to break the cycle that places so many women who lack housing at increased risk for incarceration. What was needed, the group argued, is an approach that addresses the fundamental human rights issues that underlie homelessness and incarceration.

WIP members met with public officials. They wrote op-eds. They published resources outlining what a safe move from the encampment could look like. Any housing plan, they argued, must include more than just a roof overhead. It must also provide the support needed to rebuild relationships, manage healthcare, and pursue educational and work goals. Above all, the Suffolk professors stressed, the formerly homeless need to know they’re not one small mistake away from eviction.

LIVING ON A KNIFE’S EDGE

Susan Sered, chair of Suffolk’s Sociology and Criminal Justice Department, understands how minor missteps can cascade into catastrophic outcomes—particularly for women.

Consider the case, she says, of a woman living in transitional housing who has no car but must travel miles to meet with her probation officer. Should she beg a ride from her abusive ex-partner who is still using opioids, putting her safety and sobriety at risk? Perhaps she’ll be forced to trade sexual favors for the bus fare that amounts to almost one-tenth of her monthly disability income. Or she could skip the meeting, triggering an automatic revocation of her parole. Any of these options could erase the progress she’s made to get her life and family relationships back in order, and send her back into the vortex of the criminal justice system.

Sered says these kinds of impossible choices are so common among the women she studies that whenever she provides an incentive for involvement, they always request the same thing: a transit pass. Such a basic need is easily overlooked, but addressing it is key to helping those who live on the knife’s edge between independence and institutionalization.

“On the face of it, the tent encampment at Mass and Cass is not a women and incarceration issue,” Sered says. “But when you dig a little deeper, you find out that many of those women have standing warrants and open cases. So in the process of moving them out, some of them were actually whisked off to the counties in which they have open cases.”

Sered is one of the co-founders of the Women and Incarceration Project, which seeks to educate policymakers, journalists, and the general public on issues affecting the 1.2 million women under the supervision of the criminal justice system. Between 1980 and 2019, the number of incarcerated women jumped by more than 700% nationally, according to The Sentencing Project, a D.C.-based think tank.

“We believe that empirical research is a powerful tool for opposing the U.S. epidemic of incarceration,” the group states on its website.

APPLYING A HUMAN RIGHTS FRAMEWORK

WIP is housed at Suffolk’s Center for Women’s Health & Human Rights, which was founded in 2003 by Amy Agigian, an associate professor of sociology and the center’s director. When viewed through a health and human rights framework, she says, seemingly intractable policy issues like homelessness and women’s incarceration can yield very different approaches and solutions. “We look at the failure of the state to fulfill people’s human rights as a fundamental cause of a lot of the problems,” she explains.

For Agigian, these human rights include not only familiar freedoms guaranteed by the Constitution but also things like access to healthcare, housing, and poverty relief. Many incarcerated women, she adds, are mothers. “So when they get sent away,” she says, “that has a profound impact on children.”

While many more men are imprisoned nationwide, how women experience incarceration often differs from men, and so helping those women often necessitates different strategies. For example, a higher percentage of incarcerated women struggle with substance use than men (potentially related to the fact that women are more likely to receive prescription medication). Indeed, drug-related arrests of women increased 216% over the past decade, compared to a 48% increase for men. Incarcerated women also report significantly higher rates of abuse, chronic illness, and mental health challenges than incarcerated men and nonincarcerated women. “What people find most surprising is that almost all incarcerated women have been victims of violence in their lives,” Sered says. “And for women, the strongest predictor of incarceration later in life is to have been a victim of childhood sexual abuse.”

WIP includes transgender women in its research, Agigian says, “because trans women go through the same kinds of life experiences as any other women, and may be even more likely to have traumatic experiences and be victimized than other women.”

AN INCARCERATION ‘POLICY WINDOW’

Massachusetts is an interesting state for a project like this to launch: While the growth rate for female imprisonment has been twice as high as that of men since 1980, over the last decade the Bay State has seen a steady decline in the number of incarcerated women. As of 2019, Massachusetts had the lowest incarceration rate of females in the country.

But Massachusetts is also home to MCI-Framingham, the second-oldest women’s prison in the U.S. When it opened in 1877, MCI-Framingham was regarded as a pioneering improvement over the carceral status quo, in which women who were jailed alongside men regularly faced violence and sexual abuse. Its early champions included feminist leaders like Clara Barton, founder of the Red Cross. But nearly 150 years later, the facility stands in disrepair, and in early 2020 the Massachusetts Department of Correction announced it would close the prison by 2024. State officials said they would build a new “trauma-informed” and “therapeutic” prison for women, at an estimated cost of $50 million—even though fewer than 200 women are currently incarcerated at MCI-Framingham.

WIP researchers saw this moment as an opportunity to lend their multidisciplinary expertise, and began advocating against the construction of a new women’s prison. Local activists with Families for Justice as Healing, a Boston-based grassroots organization, were already fighting back against the state’s proposed plan, holding rallies and filing transparency complaints.

Central to WIP’s case is the lack of evidence supporting the effectiveness of prison-based mental health or trauma treatment programs. Instead, the researchers argue that for a fraction of the cost both to incarcerate women annually and to construct a new facility, lawmakers could redirect resources to strategies actually proven to help, such as secure housing. They have also advocated for strategies that would release a large majority of the over 160 women currently held at MCI-Framingham under existing state policies, and for several pending bills in the Legislature that could decarcerate the state even further.

Rachael Cobb, chair of the Political Science & Legal Studies Department, and a political scientist involved in the project, calls this moment an incarceration “policy window” because so many people and institutions are talking about criminal justice from different perspectives—from police commissioners raising alarms about crime, to Black Lives Matter activists calling out patterns of systemic racism, to progressive district attorneys advocating for bail reform.

“We have an opportunity to get out there, because this is a time when op-eds can make a big difference,” Cobb says. “I think people are receptive to the kind of public airing of ideas and sharing of information about incarceration in a way they might not have been a few years ago.”

COMMUNITY-BASED, COMMUNITY-INSPIRED SOLUTIONS

Many Americans have spent little time thinking about incarcerated women, beyond watching Netflix’s award-winning comedy-drama Orange Is the New Black. WIP scholars say a lot of their time is spent trying to simply educate the public and correct misconceptions. “Women who have criminal records really, really struggle to get jobs,” says Sered, who has been following the same cohort of women released from MCI-Framingham for more than a decade.

While men with criminal records face barriers to employment too, they typically find success in jobs, such as furniture moving, that don’t involve client-facing work. Child care, education, and working with the sick and elderly are all typically female-dominated professions, but can be very hard for women with criminal records to access or re-enter.

Over the next year, WIP plans to disseminate its research further, and expand its work with more local community organizations, activists, and legislators. Some ideas they suggest to reduce incarceration include decriminalizing pain-reducing substances and sex work, and having well-trained and resourced medics and social workers on mobile crisis-intervention teams, instead of police, respond to mental health emergency calls.

Suffolk University Law School Professor Erin Braatz, who works in the areas of criminal law and penal reform, says one goal of the WIP effort is to expand the conversation about what exactly punishment should look like in the 21st century. “To even have a hearing in front of the legislature where people are invited to share their ideas on that question would be a success,” she says. What makes the Women and Incarceration Project both unique and valuable, Braatz says, is that it’s “based in the community, and attempting to reckon with a problem that can only truly be addressed through learning from and collaborating with members of that community.”

Then again, she adds, working together on a local level to respond to the needs of the community has long been a Suffolk strength. “I truly believe that real criminal justice reform can only be achieved through these types of local-level projects,” Braatz says. “For that reason, Suffolk is ideally positioned to play a role in shaping these debates and conversations and moving them forward.”

The leaders involved in the effort say they feel lucky to work for a university that values this kind of public engagement, and that encourages scholarly activity beyond the realm of academic publishing. “This work is actually respected at Suffolk,” Sered says. “Nothing that I write is just for academic journals alone. We’re all really committed to getting this research out into the world.”

Originally published in Vox on May 7, 2022.
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In 2018, more than two decades after Dutch physician Rebecca Gomperts first became an activist to deliver abortion pills around the world, she turned to the United States. For years she had dedicated her life to working in countries where the procedure was illegal, and was firm in her refusal to avoid the US, where safe, legalized access was still available. “I think this is a problem the US has to solve itself,” she explained in 2014.

But following the election of President Donald Trump, the desperate requests she received from Americans went up, and the cost barriers in the US were glaring.

So Gomperts launched a new nonprofit organization based in Austria — Aid Access — with the goal of providing affordable and accessible abortion services to people in the US.

Over the past four years, Aid Access says it has delivered abortion medication — mifepristone and misoprostol — to more than 30,000 Americans across all 50 states, including the 19 conservative states that currently ban telemedicine abortion.

The organization plays a unique role in the US reproductive rights ecosystem by successfully exploiting legal loopholes that make it easier for an overseas doctor to care for American patients in restrictive states — a role that could become even more key if Roe v. Wade is struck down.

If the right to an abortion does get overturned, Aid Access staff say they feel confident their services could continue, in the same way they’ve been able to operate in red states that have barred other abortion groups.

So what’s the catch?

For now, the biggest one may be the big tech platforms. Aid Access needs to spread awareness about its services, and quickly. The pills, when shipped from overseas, can take two to three weeks to arrive, and Aid Access prescribes the two medications up to the first 10 weeks of pregnancy. But because it operates outside the formal US health care system, Aid Access says it has been penalized by search engines and social media giants that have tried to tackle the spread of Covid-19 misinformation.

Aid Access still pops up on Google if you search the organization’s name, but most users had come to the site while searching for terms like “abortion by mail” and “abortion pills.” Following a series of algorithm updates beginning in May 2020, Aid Access says it no longer shows up in top results for general medication abortion searches — and that ads from its sister organization, Women on Web, which serves countries all over the world, are frequently removed or rejected from Facebook and Instagram for dubious reasons, like “language … that is likely to offend users.”

Republicans might not be able to stop Aid Access right now, but it appears that Silicon Valley can.

How Aid Access works

The Aid Access model goes like this: If you need an abortion, you fill out an online consultation form. If you’re early enough in your pregnancy and deemed eligible, then you’re referred to a provider. People living in the country’s more liberal states and Washington, DC, are referred to a US-based provider who fills prescriptions that ship typically in two or three days. For women living in the 31 states that Aid Access counts as having tighter abortion restrictions, Gomperts sends the prescriptions to a pharmacist in India, who then mails the pills directly to patients in the US. (Aid Access chooses India in part because the country produces regulated, high-quality generics, Gomperts has said.)

Gomperts and the women she prescribes pills for operate in something of a legal gray area. As a result of being registered to practice medicine in Austria, she is subject to Austrian law, and therefore exempt from specific rules and regulations affecting doctors in the US, like state requirements for ultrasounds or 72-hour waiting periods. And while personal imports of drugs from other countries are usually against US law, the Food and Drug Administration (FDA) has said it generally avoids going after individuals who bring medicines in for personal use.

It’s a model Gomperts developed first in 2005 with Aid Access’s older sister organization. Since its founding, Women on Web says it has delivered abortion pills to more than 100,000 women across the world, reaching pregnant patients in countries with restrictive laws, like Sudan, Hungary, and Brazil. In 2018, Gomperts set up Aid Access under a separate corporate structure, to serve the US while protecting Women on Web from the aggressive US anti-abortion movement.

Activists note that medication abortion is far safer than many painkillers easily purchased over the counter, and the World Health Organization maintains that individuals can self-administer the drugs without direct supervision of a health care provider during their first trimester. New Lancet research published in February affirmed the safety of the Aid Access model, which also provides the medication at significantly lower cost than in-person surgical abortions or even the new crop of US startups like Hey Jane, Abortion on Demand, and Carafem.

Aid Access says its work will continue in a post-Roe environment, and that requests for pills and information tripled in the wake of Monday’s leaked Roe opinion draft.

Christie Pitney, a midwife who fills prescriptions for Aid Access patients in California, Massachusetts, Oregon, and DC, said that while patients in some states with trigger bans may have to switch from US-based providers like Pitney to Gomperts, Aid Access will keep serving them. “We’ll still be here,” she said.

“We’re pretty nonplussed, to be honest,” Pitney told Vox. “I don’t see a route [to stopping us]. It’s not to say that it’s impossible, I just don’t see a route for politicians to eliminate access to Aid Access; they just don’t have the jurisdiction to criminalize an international doctor.”

Other international doctors could also join Aid Access if Roe were struck down to help Gomperts prescribe the abortion pills, though she told Vox that thus far she has not been approached by any physicians.

A struggle for internet traffic

Despite the unique strategy Aid Access and Women on Web deploy, over the past two years, the organizations say they have been fighting against search engine algorithms that deprioritize their services, and opaque social media policies that limit or block their posts.

Earlier this year, in an interview with the New York Review of Books, Gomperts said that “the algorithms of Google are suddenly becoming the de facto gatekeeper to access to safe abortion services in the US.” When Google set out to correct Covid-19 misinformation and started elevating more health sites that were officially government-sanctioned, Gomperts said it had the side effect of demoting sites like hers.

Searches like “abortion by mail” and “online abortion” no longer led users to Gomperts’s groups, she says. Women on Web, for example, says it saw a 90 percent drop in daily global traffic after Google rolled out a new update on May 4, 2020. A subsequent update brought back some of what had disappeared, doubling its now-minuscule traffic, but then a third algorithmic update six months later took 40 percent of what remained. “We’re back to pretty low,” said Venny Ala-Siurua, the executive director.

Ala-Siurua told Vox that deprioritization in internet search results remains one of their biggest barriers. Google “keep[s] pushing up traditional health providers, brick-and-mortar clinics, but they’re missing what’s happening in the digital world today,” she said. “The algorithm is not neutral. It was built and written usually by white men in the Bay Area who might not really be in tune with what the needs are here.”

Aid Access isn’t alleging Google is intentionally restricting access to its site specifically, but Gomperts told the New York Review of Books that they might eventually launch a lawsuit over this. “The algorithms are making it much harder to find the places where you can obtain these medicines,” she said. “That is what people don’t realize: It’s Google that is filtering people’s access to information.”

Lara Levin, a Google spokesperson, told Vox that their search ranking systems “are designed to return relevant results from the most reliable sources, and on critical topics related to health matters, we place an even greater emphasis on signals of reliability.” Levin added that no update is made to benefit or penalize any one site. “We give site owners and content producers ample notice of relevant updates along with actionable guidance,” she said.

The Facebook and Instagram accounts for Women on Web have had spending restrictions placed on them for more than a year, after their ads were flagged or hidden by other users who oppose their work or who found their content “to be offensive … violent, [or] about a sensitive topic.” Some of their ads for medication abortion have also been rejected, with rationales like “Ads must not promote the sale or use of unsafe supplements, as determined by Facebook in its sole discretion.” One Women on Web Instagram post that read, “You can now order abortion pills BEFORE you are pregnant,” and included a link for advanced provision was taken down for not following “community guidelines.”

Facebook did not respond to a request for comment on the Women on Web ads specifically, but pointed Vox to company policies from Meta (Facebook and Instagram’s parent company) including ad prohibitions for direct sales of prescription drugs, and for ads promoting reproductive health products or services to people under age 18. In November 2021, Facebook also announced it would remove ad targeting options for topics people may perceive as “sensitive” — including health-related causes.

But at least one of the examples Women on Web showed Vox — the one about ordering pills before you’re pregnant — wasn’t an ad. It was a regular post to the group’s Instagram profile that they didn’t pay to amplify or target.

The algorithmic battles playing out reflect broader challenges faced by tech companies, which are under pressure to crack down on misinformation and propaganda and to take clearer stands on polarized political issues that users may be researching. The last few years have also brought greater attention to the ways in which machine learning and AI more broadly can reflect bias and discrimination, even while purporting to be objective and neutral.

“We have to be careful not to frame questions as one of adapting to technology,” said David Broniatowski, a professor at George Washington University who has studied anti-vaccination communities online. “The technology is out in the world, so we should ask how to remake technology so we can achieve goals that are of best benefit to society.”

Aid Access has withstood legal challenges, so far

Aid Access has faced one regulatory challenge, in 2019, when the FDA sent the group a cease-and-desist letter, claiming that its generic mifepristone drug represented a “misbranded and unapproved” drug that posed risk to consumers. (The FDA approved one brand of mifepristone, Mifeprex, in 2000, and in 2019 approved a generic version.)

Aid Access, in turn, sued the FDA, alleging the agency was impeding Americans’ constitutional right to an abortion and that its drugs were, in fact, approved. Aid Access also maintained that the FDA had no legal jurisdiction over Gomperts. The case was dismissed in part because the FDA never took action following its letter.

The Biden administration has taken a friendly stance toward medication abortion, but a change in the White House in 2024 or beyond could mean new challenges from the FDA or other agencies. Legal threats against Aid Access without the constitutional protection of Roe might make things even more complicated.

Anti-abortion activists and lawmakers have been ramping up their efforts to crack down on abortion pills, an unsurprising development given that medication abortion accounted for 54 percent of all US abortions in 2020. In 2022 alone, according to the Guttmacher Institute, lawmakers in 22 states have introduced new legislation to restrict the drugs.

Rather than punish those who seek abortions, the slew of anti-abortion laws introduced over the past decade has targeted physicians, clinics, and anyone else who helps to “aid and abet” someone who has an abortion, as Texas’s recent ban put it. Abortion activists have worried about the criminalization of patients, but so far efforts have been limited and largely unsuccessful.

Whether any of these new laws could affect Aid Access’s operations or the patients who seek out its services remains an outstanding question. It’s hard to know what abortion access in the US will look like in a year, or five.

But for Americans seeking to end their pregnancies now — whether they live in red states with heavy abortion restrictions or in blue states with more liberal laws but heavy financial barriers — Aid Access represents a lifeline. If they can find it.

Originally published in Vox on April 17, 2022.
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Alicia Cruz was homeless before she and her four daughters moved into a newly vacant apartment in Lancaster City, Pennsylvania, about three years ago. As she stood in the kitchen and watched dirty water clog up the sink, the landlord promised he’d have it fixed before they moved in.

But it was just the beginning. The ceiling of her apartment was cracked; the heating was inadequate, so she and her daughters are usually freezing; due to water damage, they regularly deal with roaches. She’s tried to leave but couldn’t find suitable alternatives she could afford.

“If I knew then what I know now, I probably would have ran out the door and stayed homeless a little longer,” Cruz testified to Pennsylvania state lawmakers in December, later adding: “To this day, the landlord won’t fix this place, but he wants to collect my rent money. It’s just really sad.”

The nation’s affordable housing crisis has gotten some semblance of attention — with journalists writing stories on the rising cost of rent, the scarce supply of new housing, the looming threat of eviction — but one aspect of the crisis has gone consistently overlooked. On top of the severe housing shortage that currently exists, nearly 6 million homes nationwide have moderate to serious home health hazards. They require repairs that, if left ignored, will make them uninhabitable, and eventually they’ll disappear from the market altogether.

The National Low Income Housing Coalition, a research and advocacy group, estimates a shortage of 7 million affordable housing units for low-income renters, but those figures don’t account for all the existing affordable units that stand at risk of demolition.

Issues like lead paint, leaky roofs, and knob-and-tube wiring don’t just leave tenants and homeowners in substandard, unsafe housing. They also leave families — mostly poor families — shut out from energy efficiency programs the federal government already funds to upgrade homes. Due to inflexible program restrictions, homes with outstanding repairs aren’t eligible for existing weatherization subsidies, despite those families arguably needing them the most. Addressing this problem could help solve both the affordable housing and the climate crisis at once.

Low-income households in particular have a lot to gain from the federal Weatherization Assistance Program (WAP), which provides funds to repair or replace heating and cooling systems, treat windows, or make any of the other upgrades that can not only reduce home energy use but also substantially reduce utility bills. But as it stands now, it’s people living in homes with no mold, asbestos, or structural issues who can access those WAP funds. Low-income homeowners and renters must first find the resources to fix their units, with some repairs running as high as $50,000.

The sheer number of homes barred from weatherization due to outstanding health and safety issues is immense. In Connecticut, for example, between 2017 and 2019, nearly 25 percent of income-eligible homes were barred from weatherization upgrades. Steve Luxton, who heads a nonprofit focused on helping Philadelphians weatherize their homes, told me 55 to 65 percent of those in his city who apply for WAP assistance are denied because of structural issues. And nationally, according to a recently published E4TheFuture analysis, 10 to 30 percent of income-eligible clients are deferred from weatherization upgrades each year for health and safety problems, with those deferrals on the rise.

Not being able to weatherize homes doesn’t just present cost burdens for low-income households, it also has a direct impact on the climate crisis. The energy required to cool, heat, and provide electricity to residential buildings accounts for 20 percent of annual energy use in the US, with older homes emitting more carbon.

Included in the $1 trillion infrastructure bill Congress passed in November was a $3.5 billion investment in the federal weatherization program, with the stated goal to increase energy efficiency, increase health and safety, and reduce annual energy costs for low-income households. A 2015 Department of Energy evaluation of WAP found the energy efficiency upgrades it subsidized led to households saving an average of $283 per year on their bills.

The Biden administration estimates the new infusion of funds from the infrastructure bill will allow the government to help 450,000 households weatherize over a decade. But low-income homeowners and tenants will remain shut out from the new money if they aren’t able to make the repairs they need.

“There will always be a tension, saying, ‘Okay, should I spend a thousand dollars to fix that roof when I could weatherize someone else’s house now?” said Charlie Harak, senior attorney for energy and utilities issues at the National Consumer Law Center. “But I’d go so far as to say that often the houses most in need of weatherization get walked away from.”

It’s certainly not easy to come up with money for those repairs. If you’re a low-income homeowner, you would likely struggle to get an affordable home improvement loan from a bank. You may have less than optimal credit, and depending on where your house is located, the house itself may have low equity. If you’re a renter, your landlord probably feels little pressure to make your unit energy efficient, given that it’s tenants, not the property owners, who typically shoulder the electricity and gas bills.

According to US census data, low-income households spent an average of 8.1 percent of their income on energy costs, compared to 2.3 percent for wealthier households. It’s not uncommon for poor families to pull back on other expenses, like medicine, groceries, or child care to cover their energy bills.

Jeff Genzer, who has served as counsel for the National Association of State Energy Officials since 1986, told me the intersection of housing and energy issues is one of the most difficult problems he’s worked on in his career. Steve Cowell, executive director of E4TheFuture and a longtime energy efficiency advocate, said the problem originates from treating health and safety issues as a footnote.

“The whole energy efficiency world that developed over the last 30 years was focused on pieces of the puzzle, and primarily the costs and benefits of energy on an economic dollar basis,” he said. “The health, safety, and conditions of a home has just been seen in the background, a side deal.”

Experts like Cowell have been trying to urge attention on the so-called “non-energy impacts” of weatherization, such as reduced asthma, reduced missed days of work, and fewer home fires. One evaluation published in 2016 assessed that each weatherized Massachusetts housing unit yielded an estimated $1,381 in combined savings to the individual household and society, with some of those savings coming from literally preventing deaths.

The climate crisis has made this harder to ignore

When the energy efficiency movement got its start in the 1970s following the oil crisis, talk of reducing carbon emissions was simply not a salient consideration for policymakers and practitioners, and wouldn’t become one for years.

But as the stakes of the climate crisis have grown clearer, the last 10 years have marked a sea change for the energy efficiency movement. While in prior decades policymakers could ignore home upgrades when they deemed weatherization not “cost-effective,” today they have to wrestle with the fact that the low-income renters living in subsidized apartments are using even more energy than other households, typically because their units are older and built with less efficient tech.

One study published in 2019 by the American Council for an Energy-Efficient Economy (ACEEE) found that making energy upgrades — including to residential buildings — could cut greenhouse gas emissions in half by 2050. Upgrades to homes and buildings could save 30 percent on average for most buildings, ACEEE wrote, while installing sensors, automated controls, and other smart software could reduce energy use by another 15 percent.

The carbon emissions produced by old, decrepit housing are not the only environmental threat. A warming planet also threatens to put more homes into disrepair or wipe them out from the existing housing stock altogether, exacerbating our housing shortage. For example, if a fire or natural disaster doesn’t completely destroy a unit, the owner has to decide whether to then repair or demolish it. Affordable rental units are more likely to be demolished than rebuilt, given the tight profit margins they operate on.

Upgrading home energy systems won’t make those homes more capable of withstanding the effects of climate change. As Carlos Martín, the director of the Remodeling Futures Program at the Harvard Joint Center for Housing Studies, told me, energy efficiency upgrades are climate mitigation steps; they would help reduce future emissions to make the crisis less severe. But addressing home repairs, like fixing broken roofs, floors, and windows — those investments would strengthen existing housing stock to better withstand more frequent storms, flooding, and heat.

The growing affordable housing crisis has brought increased pressure to this situation. Depreciation is one of the top three threats to preserving existing affordable housing. It’s a hard issue to mobilize around though, because, like global warming, it’s a crisis we’re hurtling toward but haven’t yet reached. Weatherizing affordable homes could help avoid that fate; lowering maintenance costs can improve a property’s cash flow, which can then be used to reinvest in other capital needs.

More than a quarter of American households in 2020 reported difficulty paying their energy bills. Harak, from the National Consumer Law Center, noted that failure to pay utility bills is considered a breach of the lease in most subsidized housing, leaving the renter highly vulnerable to eviction.

“It’s a significant issue from an aspect of equity,” said Andrew Aurand, vice president for research at the National Low Income Housing Coalition. “If these people are priced out, where would they actually go?”

A first-of-its-kind legislative fix

In Pennsylvania, lawmakers are exploring a legislative solution to this problem, through a first-of-its-kind bill in the nation. Introduced in March by Democratic state Sen. Nikil Saval, the Whole-Home Repairs Act would provide eligible residents with grants up to $50,000 to make needed home repairs, and small landlords could apply for the same amount in forgivable loans. The bill would also aim to ramp up investments in workforce development, to address the growing shortage of qualified workers able to address the repairs.

By finally fixing up the homes, tenants like Alicia Cruz would not only be able to live in safer and healthier environments, they’d also be finally positioned to access weatherization dollars. More than 280,000 occupied homes across Pennsylvania are estimated to have moderate to severe physical issues, ranging from exposed wiring to failed plumbing and leaky windows. Environmental justice activists note that making the housing repairs would also help those being targeted with offers by property developers, and help more seniors age in their own homes, a strong preference for many elderly families who live on fixed incomes.

Genzer, of the National Association of State Energy Officials, told me he thinks Saval’s proposal is an “excellent bill” but that the $50,000 price tag for repairs “tells you a lot” about how difficult this problem can be politically.

Still, it’s not a long shot. Though Saval is a left-wing Philly Democrat, his bill has captured support from some heavyweight Republican legislators in Harrisburg, including Republican Sen. Pat Browne, chair of the state appropriations committee. Another is Sen. Dave Argall, chair of the state government committee, who has worked on blight issues for more than a decade.

“I represent a lot of struggling old mining communities where most of the coal mining stopped in the 1940s and 1950s,” Argall told me. “What I liked about Sen. Saval’s bill is if we help fix up the housing before they completely go to rot, that’s better for the people living in the homes, better for the next-door neighbor, and better for the taxpayer if they don’t have to fund millions and millions in demolition costs.”

Argall said he thinks the bill has “a very good chance” of passage in this year’s budget cycle, though the precise dollar amount is still being negotiated. Saval is pointing to the state’s $6 billion budget surplus and unspent Covid-19 relief dollars as strong sources to seed the new program.

Saval campaigned on affordable housing issues, but his office said data released last spring by the progressive polling firm Data for Progress was particularly instrumental in shaping some of their thinking around the politics. A survey of likely voters across Pennsylvania found 87 percent of respondents supported weatherizing homes to make them more energy efficient, including 83 percent of Republicans and 90 percent of independents.

While the home repairs bill would not itself go toward making energy efficiency upgrades, it would position more homes to be able to access the WAP funds. “We’re trying to make that federal money work more effectively,” Saval told me.

On the federal level, the Department of Energy has been slow to take this problem seriously, though advocates say conversations are starting to happen. The pandemic also elevated the conversation around staying home, indoor air quality, and respiratory illness.

“There’s some new efforts to think through this,” said Cowell, of E4TheFuture. “But they still struggle to decide if weatherization should go beyond just the straight economic savings.” The federal agency still doesn’t require states to report the number of homes deferred from the weatherization program for repairs, and not all states track those “weatherization walkaways” consistently.

Some states can dedicate a portion of their Low Income Home Energy Assistance Program (LIHEAP) funds for weatherization, a pot of money that tends to have a bit more flexibility than WAP funds in how it can be spent. Still, spending patterns for LIHEAP vary dramatically across states, and most of the money still goes for its primary purpose — helping poor families defray the cost of their energy bills. In 2015, less than 10 percent of total federal LIHEAP funds were used on weatherization.

In Congress, weatherization has bipartisan support, but there’s been less momentum to address the home repair issues that prevent energy upgrades. Still, Democratic Rep. Dwight Evans, who represents Pennsylvania’s Third Congressional District, including parts of Philadelphia, told me he thinks Saval’s Whole-Home Repairs Act could become a national model. After all, Pennsylvania is showing how blight issues can bring collaboration across the aisle. And a Data for Progress poll from January found investing in energy efficiency for buildings to be one of the most popular climate policies nationally, especially given high energy prices.

“I think this program has great potential — it can be a vital part of the federal, state, and local investment that we need,” Evans said. “I’ve supported and voted for increased federal investments in affordable housing, and this would fit well with that.”