Originally published in Vox on February 23, 2024.
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One week ago, Alabama’s Supreme Court issued a now (in)famous 131-page decision that invoked God to claim that frozen embryos count as “children” under state law.

The unprecedented legal opinion, which came out of a tragic negligence case in which families sued someone who had accidentally destroyed their frozen embryos, has sent shockwaves across the country.

Policymakers, parents, and prospective parents are realizing it could seriously imperil in-vitro fertilization (IVF) or dramatically hike its already prohibitive costs. About 2 percent of births in the US are done through IVF, which entails fertilizing eggs outside of the body and then transferring embryos to a womb.

We’re already seeing consequences.

Two days ago, the University of Alabama at Birmingham health system — the largest hospital in the state — announced it was pausing IVF, given the new risks of criminal prosecution and litigation. Since then, at least two more Alabama fertility clinics have followed suit.

Let’s be clear. This decision and its very obvious fallout are a victory for an extremist wing of the anti-abortion movement I’ve been covering for the last two years. These particular activists believe in the radical idea of “fetal personhood,” meaning they want to endow fetuses (and embryos) with full human rights and legal protection.

It’s also a reminder that the overturn of Roe v. Wade is about more than just abortion. It has ramifications for the full spectrum of reproductive health care — including birth control and fertility treatments.

Roughly one in eight couples nationwide struggles with infertility. A 2023 Pew survey found that 42 percent of US adults say they or someone they know has used treatments like IVF or artificial insemination.

“There was a time post-Dobbs where wealthier people thought they were not going to be affected … there was a sense that IVF was in a gated country club,” Stephen Stetson, the director of Planned Parenthood Alabama, told me. “But the people in this movement have been very clear about their intentions. There is a war on bodily autonomy.”

What this means for women

This week, I spoke with Tasha Coryell as she was celebrating the second birthday of her son, whom she gave birth to thanks to successful IVF treatment in Alabama.

“I had a really good experience seeking fertility treatment in Alabama, it was one of the few medical experiences I’ve had where I felt really listened to,” she told me.

Being pregnant in Alabama, though, was scary for Tasha.

“We knew there was a potential problem with our baby, and though it turned out to be something very, very minor, there was a chance I would have to have an abortion and we weren’t at all sure I would be able to get one,” she explained. “That was the most anxiety-inducing time I’ve ever experienced in my entire life.”

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Tasha and her family decided not to risk the possibility of an unsafe pregnancy in Alabama again, so after years of living in the state, they relocated last summer to Minnesota. But her 11 remaining embryos are still stored in an Alabama cryogenic facility, and she’s been considering trying for another child.

Earlier this month, before the Alabama state Supreme Court decision came down, Tasha called her fertility doctor to ask for general advice. Her doctor recommended keeping the embryos in Alabama, since they could be damaged in transport and relocation would not be cheap. But now Tasha is left to make sense of this decision. Should she move her embryos out now?

“I have no idea what’s going to happen legally,” she said. “Can Alabama force people to continue paying for embryo storage year after year after year? Do they have to exist forever?”

She knows she’s luckier than most, since she at least already has one child. “I keep thinking about people in the middle of all this who are currently injecting themselves with shots,” she said.

Even under “good” circumstances, IVFs is grueling, and it can be difficult for people to talk about. Now, for some women, it might all be for naught.

Is IVF totally over in Alabama — or, next, the whole country?

The ruling was somewhat narrow and did not weigh in on the future of other frozen embryos.

As my colleague Ian Millhiser explained, there’s a world where this decision could be relatively contained. The case is also not over; the state Supreme Court is sending it back to a district court for further litigation.

In short, this victory for the fetal-personhood movement isn’t fully set, but medical providers and patients like Tasha are already left trying to piece together answers that nobody yet has.

“It’s a climate of chaos and confusion,” Stetson, of Planned Parenthood Alabama, told me. “I can appreciate the desire of lawyers who are advising fertility clinics to be conservative. No one wants to be on the hook for any legal liability or risk of criminal prosecution if some district attorney gets the wrong idea.”

One possibility is that IVF will continue in Alabama, but embryos will be stored in other states — raising the costs and complexity of the procedure.

For the rest of the country, IVF specialists are now on high alert and warn that this first-of-its-kind decision may be just the start in courts and state legislatures.

This is all a sober reminder that for many activists, attacking reproductive health care has always been about more than just ending abortion. For these religious crusaders, nothing short of “fetal personhood” will suffice.

Originally published in Vox on February 13, 2024.
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For more than a decade, researchers and advocates have argued that housing is a fundamental part of health care. Beginning this fall, for the first time, federal Medicaid dollars will start going toward paying some people’s rent.

It’s a significant policy development. Congressional regulations have long barred Medicaid funds from being used to pay for rent for people staying outside of nursing homes or medical facilities like hospitals. And while some states have used philanthropy or state-based Medicaid funding to pay for housing, those pots of money were extremely limited. Now, with rates of unsheltered homelessness reaching record highs in 2023, and rents growing to their most unaffordable levels ever, some states are preparing to use federal Medicaid dollars in the hopes that health will improve as housing stabilizes.

The Biden administration has made this possible through a longstanding Medicaid waiver program that allows states to test out new Medicaid ideas.

For nearly a decade, the federal agency that runs Medicare and Medicaid has been warming to the idea that housing could be health care. Since 2015, the Centers for Medicare and Medicaid Services has affirmed that Medicaid funds could go toward services that help people move into new housing, like moving costs or security deposits. In 2018, an influential federal commission told Congress that, while it’s long been known that poor housing conditions can worsen health outcomes, more recent data suggests that providing supportive housing to chronically homeless people also reduces ER visits in ways that case management or other outpatient services does not.

The “housing is health care” mantra got another major boost during the pandemic, when calls to stay at home to avoid catching and spreading disease grew louder and more urgent. Communities that halted evictions saw lower rates of Covid-19, a stark example of how access to housing is linked to health.

And in 2022, the Biden administration encouraged states to consider using Medicaid dollars for “health-related social needs” like housing, nutrition, and transportation — part of a broader White House effort to address social determinants of health.

“We think it’s incredibly exciting,” Dan Tsai, the deputy administrator and director of the Center for Medicaid and CHIP Services, told me. “This is a firm, clear stance, and we spent about a year of this administration working through how to define and create with guardrails the role of Medicaid in housing and nutrition.”

Tsai said their conclusion was based on both common sense and evidence-based practices, that for some groups of people, throwing “the same old against the wall” just would not drive better health.

Jeff Olivet, the executive director of the US Interagency Council on Homelessness, similarly told me he sees the ability to use Medicaid dollars for purposes like rent as “a real potentially game-changing set of supports” to help people exit homelessness and then stay stably housed.

Not everyone thinks this possibility is a good move for Medicaid, an already strained federal program with notoriously low reimbursement rates for doctors that disincentive treating patients. Just 3 percent of a state’s Medicaid spending can go toward “health-related social needs” like housing, but that could still easily amount to billions of dollars annually. Others doubt the claims that paying for housing will drive down overall government spending.

Sherry Glied, a dean and professor of public service at New York University, warned recently of “mission creep” in health systems, arguing that having hospitals and other medical institutions focus on the provision of social services could be a “dangerous distraction” from their core mission of serving patients, and one that policymakers should discourage.

The failure of Congress to dedicate more money to agencies like the Department of Housing and Urban Development is how we got to this point, said senior policy director for National Health Care for the Homeless Council Barbara DiPietro.

“More and more states are desperate to find any help, and that’s why they’re turning to Medicaid because they’re not getting real assistance from HUD,” she told Vox. “And Medicaid is an entitlement program while housing is not.”

The new pilot program authorizes Medicaid dollars for up to six months of rent and could herald much bigger shifts down the line if state results show improvements in health outcomes or cost-savings. It could also augur much larger shifts across state and federal governments to bring about more comprehensive visions of health care.

Arizona and Oregon will go first

The federal government has approved a handful of states to use waivers to finance rental assistance for up to six months. The first states to put this into practice are Arizona starting this October, and Oregon this November. The two are planning to target different subpopulations of Medicaid beneficiaries, and both are scrambling to figure out how to make this all possible given shortages of affordable housing.

Oregon’s Medicaid program currently provides coverage to roughly 1.5 million Oregonians, and the state estimates 125,000 of those people will soon be eligible to qualify for rental assistance under this new waiver. Oregon is opting to target beneficiaries at risk of becoming homeless, in effect using the funds as a preventive tool to help stave off the devastating economic, physical, and mental harms that come with losing one’s home. Individuals will literally get a “prescription” for housing.

To refer eligible people, the state will look to partner with community-based organizations. Housing nonprofits that get involved in this work will need to train their caseworkers as certified community health workers.

“It’s a little scary for them, because they don’t want to become medical providers in the same way a doctor doesn’t want to become a housing provider,” Dave Baden, the deputy director of Oregon’s Health Authority, told me. “We can’t medicalize the housing world.”

Over time, Baden hopes the state will be able to use this kind of funding to pay rent for people living on the streets, but he thinks Oregon needs to increase its housing supply first.

“This Medicaid waiver is not magically going to make housing exist, and I feel like we would have gummed our work to focus on those who were houseless to start with,” he said. “I don’t want to create a false benefit where we say, ‘Hey, Amy, here’s six months of rent, oh, I’m sorry I don’t have any housing for you.’”

Arizona, by contrast, is planning to target people designated as having a serious mental illness, building off a similar but much smaller state program that subsidizes rent for about 3,000 Medicaid beneficiaries each year.

That program, which is not time-limited, has been considered an extraordinary success: State data showed financing rent led to a 31 percent reduction in ER visits, a 44 percent reduction in inpatient hospital stays, and savings overall to Arizona’s Medicaid program of more than $5,500 per member per month.

“That’s one of the big reasons we felt so strongly about pursuing [the 1115 waiver] and being able to federalize some of that work,” said Alex Demyan, an assistant director with Arizona’s Health Care Cost Containment System. “We’re in a unique and advantageous position because we have a runway.”

With a significant affordable housing shortage, Arizona is looking to authorize a new kind of housing provider to help with supply issues, known as an “enhanced shelter.” These will be new organizations that contract with Medicaid to provide mostly congregate housing, and get reimbursed on a per-diem basis.

Demyan sees the opportunity to use Medicaid for rent as potentially transformative. “It’s a huge deal; this kind of cutting-edge work is really what makes working in Medicaid so rewarding in a lot of ways,” Demyan told me. “We get to play around in the sandbox of health policy and do things differently. I don’t think it’s any secret that there are better ways that we can do things.”

The fine print

As Oregon and Arizona — as well as other states that have applied to use federal Medicaid dollars for rent like New York, California, Hawaii, and Washington — prepare for the opportunity, they are hoping to build collaboration between government agencies, private companies, and community nonprofits that historically have rarely worked together.

“There has to be some system-level linkage between the housing and homelessness systems and the medical services; otherwise, we are very concerned about what will happen to people at the end of their six months,” said Marcella Maguire, the director of Health Systems Integration for the Corporation for Supportive Housing. “This funding will put more people into an already underresourced system. Long-term, I think it will reduce strain, but short-term it will increase strain.”

DiPietro, of the National Health Care for the Homeless Council, said she has some worries about how states might use this new Medicaid opportunity to jump people ahead of those waiting in the established line for subsidized housing, or even how receiving Medicaid funding could threaten their eligibility for other homeless services programs.

Olivet, of the US Interagency Council on Homelessness, said the eligibility issue is “certainly on our radar screen” and that his agency wants to serve as “connective tissue” to ensure federal policies are implemented in a strategic way. But state Medicaid departments have a “tremendous role” to play in shaping the specifics of each waiver, Olivet added, and coordination between health and housing providers “is where the real work will happen.”

Richard Cho, a senior housing and services adviser at HUD, told me there’s legal precedent for these kinds of eligibility concerns and that his agency is working closely to provide technical assistance to states.

When asked if he thinks Medicaid could one day fund rent for longer than six months, Tsai, of CMS, emphasized the importance of getting data first from these pilots. “It’s a huge first step,” he said. “No one believes Medicaid is here to supplant or replace the role of housing and nutritional agencies, but at the same time, clearly there’s a better way.”

The cost-effectiveness gamble

One undoubtedly appealing aspect of the policy proposal is that by paying for housing, Medicaid spending could ultimately go down over time, similar to how it worked with Arizona’s smaller program. It’s well-documented that people experiencing homelessness use significantly more health care resources on average than people with stable housing.

Proponents point to some encouraging research to back the idea, like a California permanent supportive housing program that reduced the use of expensive medical care and resulted in a roughly 20 percent net savings of total public cost. Another program in New York reduced inpatient hospital days by 40 percent, inpatient psychiatric admissions by 27 percent, and ER visits by 26 percent.

But other research evidence is less persuasive. One literature review published in 2022 found “mixed and mostly low-certainty evidence” that interventions to drive housing affordability and stability led to improved adult health outcomes. Another study published this month found participants had no difference in ER visits, inpatient use, or chronic disease control, but did report real mental health improvements, particularly from housing providers who showed them compassion.

“The success of health care–based housing interventions must not be judged solely by short-term chronic disease control and changes in health care use,” the study authors argued. “Given the complexity of US health care systems, innovations often struggle to demonstrate return on investment … [and] had our evaluation measured only health care use and chronic disease control, we would have overlooked the strong relational connection between patients and their advocates and missed the housing program’s possible effects on the social burden of disease in the current epidemic of social isolation in the US.”

Paula Lantz, a professor of health policy at the University of Michigan, told me she’s very supportive of Medicaid programs getting into housing interventions but has doubts about whether it will ultimately reduce costs, and notes there are moral challenges of really studying that question over time. “If you have a bunch of people in a control group who you know need services and help and you’re using them for research, the longer [they’re denied help], the larger the ethical issues there are,” she said.

Lantz says she worries that if the waivers don’t save Medicaid money, critics might seize on that to attack health care spending more broadly. Demyan, the assistant director with Arizona’s state Medicaid program, told me he would not be surprised if there’s “an initial bump in increase in cost of care” as states transition to this new model.

And what if it’s not, ultimately, cost-effective?

Tsai, the federal Medicaid official, said he’s confident there are “inefficiencies” in the system, and that governments can use funding in “wiser” ways to target certain groups of people. He also stressed the need to think about public savings over time, to remember some that many of the country’s biggest health disparities didn’t happen overnight.

Still, Tsai acknowledges, there is currently a lot of “unmet need” in health care, and saving money isn’t the only thing that matters. “That is why we want to evaluate very objectively,” he said, “and why we want to look at both health outcomes and cost.”

Originally published in Vox on February 23, 2024.
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Quietly and with little fanfare, the idea of building new publicly owned housing for people across the income spectrum has advanced in the United States.

Governments have successfully addressed housing shortages through publicly developed housing in places like Vienna, Finland, and Singapore in the past, but these examples have typically inspired little attention in the US — which has more restrictive welfare policies and a bias toward private homeownership.

Then one US community started exploring social housing with a markedly more American twist: Leaders in Montgomery County, Maryland — a suburban region just outside Washington, DC, with more than 1 million residents — said they could increase their local housing supply not by ramping up European-style welfare subsidies but through essentially intervening in the traditional capitalist bidding process. Government, when it wants to, can make attractive bids.

Now, with an acute nationwide housing shortage, and declining home construction due to high interest rates, the idea is spreading, and more local officials have been moving forward with plans to create publicly owned housing. They are very clear about not calling it “public housing”: To help differentiate these projects from the typical stigmatized, income-restricted, and underfunded model, leaders have coalesced around calling the mixed-income idea “social housing” produced by “public developers.”

“What I like about what we’re doing is all we have effectively done is commandeered the private American real estate model,” Zachary Marks, the chief real estate officer for Montgomery County’s housing authority, told me in 2022. “We’re replacing the investor dudes from Wall Street, the big money from Dallas.”

By offering private companies more favorable financing terms, Montgomery County hoped to move forward with new construction that they’d own for as long as they liked. They had plans to build thousands of publicly owned mixed-income apartments by leveraging relatively small amounts of public money to create a revolving fund that could finance short-term construction costs. Eighteen months ago, this “revolving fund” plan was still mostly just on paper; no one lived in any of these units, and whether people would even want to live in publicly owned housing was still an open question.

Answers have since emerged: The first Montgomery County project opened in April 2023, a 268-unit apartment building called The Laureate, and tenants quickly came to rent. It’s not the kind of public housing most Americans are familiar with: It has a sleek fitness center, multiple gathering spaces, and a courtyard pool. “We’re 97 percent leased today, and it’s just been incredibly successful and happened so fast,” Marks said.

Encouraged by the positive response, Montgomery County has been barreling forward with other social housing projects, like a 463-unit complex that will house both seniors and families, and another 415-unit building across from The Laureate set to break ground in October. While construction has lagged nationwide as the Federal Reserve worked to rein in inflation, private developers in Montgomery County have been able to partner with the local government, enticed by their more affordable financing options.

As word started to get around, city leaders elsewhere began reaching out, curious to learn about this model and whether it could help their own housing woes. Montgomery County was getting so many inquiries, they decided to host a convening in early November, inviting other officials — from places like New York City, Boston, Atlanta, and Chicago —to tour The Laureate and talk collectively about the public developer idea. Roughly 60 people were in attendance.

“I am very bought into the Zachary Marks’s line that there is every reason for cities to be building up a balance sheet of real estate equity and we should be capturing that and using it to reinvest in public goods,” said one municipal housing leader who attended the Montgomery County conference and spoke on the condition of anonymity because they were not authorized to talk to the media. “That’s the vision — and you can just describe it in so many ways. You can say we’re socializing real estate value for public use, or you can describe it as we’re doing public-private partnerships to invest in our communities.”

Paul Williams, who leads the Center for Public Enterprise, a think tank supportive of social housing, said growing interest in the public developer model has even led to new conversations with the Department of Housing and Urban Development. “Public agencies are clearly hungry for tools that allow them to produce a lot more housing, and in the past year and a half we’ve gone from working with Montgomery County and Rhode Island to establishing a working group with a few dozen state and municipal housing agencies who come to our regular meetings,” he told Vox. “That’s gotten HUD’s attention, and we’re now talking with them about ways the federal government can support this kind of innovation.”

Atlanta’s leaders are on track to implement the Montgomery County model

Perhaps no city has run as fast with the Montgomery County idea than Atlanta, Georgia. The city’s mayor, Andre Dickens, took office in early 2022 and set an ambitious goal to build or preserve 20,000 affordable housing units within his eight-year term. The Dickens administration wanted to find ways to do this that didn’t depend on the whims of Republicans in the state legislature or federal government.

One of the key strategies Dickens’s team has embraced is making use of property the city already owns, such as vacant land. “We did not have a good sense of what we had, what we did not have, and what was the best use for any of it,” said Josh Humphries, a senior housing adviser to the mayor.

The Dickens administration convened an “affordable housing strike force” to get a better understanding of the city’s inventory and started studying affordable housing models around the world, including social housing in Vienna and Copenhagen. Atlanta leaders also participated in a national program called Putting Assets to Work and learned about the efforts in Montgomery County.

Humphries said what “really sealed the deal” on social housing for them was simply the scarcity of alternative tools to build affordable housing, since they were already exhausting all the available funding they had from the federal Low-Income Housing Tax Credit (LIHTC).

By the summer of 2023, armed with money from a city housing bond, the Atlanta Housing Authority’s board of commissioners voted to create a new nonprofit that would help build mixed-income public housing for the city. Leaders estimate it could lead to 800 new units by 2029.

Atlanta’s first bid for private-market developers to construct social housing went out last month, and Humphries says they’re excited about how their new financing could spark new partnerships. “The combination of tools that we plan to use that are similar to what they’re doing in Montgomery County, like being able to decrease property taxes and have better interest rates in your financing, is very enviable,” Humphries said. “It has allowed us to have conversations with market-rate developers who maybe otherwise wouldn’t be interested because they haven’t been able to figure out how to make their other [private-sector] projects work.”

Boston wants to move forward with social housing, and Massachusetts might help

Since 2017, Boston has been working to redevelop some of its existing public housing projects by converting them into denser, mixed-income housing. Kenzie Bok, who was tapped by the city’s progressive mayor last spring to lead the Boston Housing Authority, said that existing work helped pave the way for leaders to more quickly embrace the Montgomery County model. As in Atlanta, Bok and her colleagues have been trying to figure out how to build more affordable housing when they have no more federal tax credits available.

“I think everyone in the affordable housing community is looking around and saying, ‘Gee, we have this [low-income housing tax credit] engine for development but it doesn’t have capacity to meet the level we need,’” Bok told me. And while the federal government could increase the tax credit volume, that requires action in Washington, DC, that for years has failed to materialize.

Bok grew interested in the Montgomery County model since it seemed to offer a way for her city to augment its affordable housing production without Congress. Bok was also intrigued by the potential of the revolving fund to spur more market-rate construction in Boston, which has slowed not only because of rising interest rates but also because institutional investors typically demand such high rates of return.

“The default assumption is that affordable units are hard to build and market-rate ones will build themselves from a profit-motive perspective,” Bok said. “In fact, we have a situation now where ironically it’s often affordable LIHTC units that can get built right now and other projects stall out.”

Bok and her colleagues realized it’s not that mixed-income projects don’t generate profits — those profits just aren’t 20 percent or higher. Mixed-income affordable housing wouldn’t need to be produced at a loss, Boston leaders concluded, they just might not be tantalizing to certain aggressive real estate investors. By creating a revolving fund and leveraging public land to offer more affordable financing terms, Boston officials realized they could help generate more housing — both affordable and market-rate.

In January, in her State of the City address, Boston Mayor Michelle Wu pledged to grow the city’s supply of public housing units by about 30 percent in the next 10 years, with publicly owned mixed-income housing being one way to get there.

To help move things forward, state lawmakers are also exploring the idea. This past fall, Massachusetts’s governor put placeholder language in a draft housing bond bill to support social housing and a revolving fund. The specifics are likely going to be hashed out later this spring, but the governor’s bond bill is widely expected to pass.

In Rhode Island, too, state-level interest in supporting the notion of publicly developed affordable housing has grown. Stefan Pryor, the state’s secretary of housing, attended the Montgomery County, Maryland conference in November, and Rhode Island recently announced it would be contracting with the Furman Center, a prominent housing think tank at New York University, to study models of social housing. “We look forward to the study’s observations and findings,” Pryor told Vox.

Can mixed-income housing help those most in need?

Lawmakers intrigued by what Montgomery County is doing praise the fact that publicly owned mixed-income housing units theoretically offer affordable units to their communities forever, unlike affordable housing financed by the Low-Income Housing Tax Credit that can convert into market-rate rentals after 15 years. Leaders also like that after some initial upfront investment, the publicly owned projects start to pay for themselves, even delivering economic returns to the city down the line.

But while housing complexes like The Laureate can offer real relief to struggling middle-class tenants — a quarter of The Laureate’s units are restricted to those earning 50 percent or less of the area median income — an outstanding question is whether the social housing model could also help those who are lower-income, who might require even more deeply subsidized housing.

In Washington, DC, some lawmakers have been exploring the social housing idea, and one progressive council member introduced a bill calling to support mixed-income housing accessible to those making 30 percent or less of the area’s median income. But critics of the bill say that the rents of those living in nonsubsidized units would have to be so high to make that rental math work.

A housing official speaking on the condition of anonymity told me they think it’s okay if the social housing model can only really work to support more middle-class tenants in neighborhoods that charge higher rents because leaders still have financing tools to build more deeply affordable housing in lower-cost areas. In other words, social housing can grow the overall pie of affordable units throughout a city.

Other leaders, like in Boston and Atlanta, told me they’re exploring how they could “layer” the mixed-income social housing model with additional subsidies to make them more accessible to lower-income renters.

Marks, from Montgomery County, knows there’s still a lot of stigma and reservations about American public housing, which many perceive as being ugly, dirty, or unsafe. Few understand that many of the woes of existing public housing in the US have had to do with rules Congress passed nearly 100 years ago, such as restricting the housing to only the very poor. Besides getting his message out, Marks said he likes to just have people come see for themselves what’s being done.

“The temperature immediately comes down when people can walk around, see how attractive it is, how it’s clearly a high-quality community with nice apartments,” he said. “It’s why getting proof of concept is so important.”

Originally published in Vox on February 5, 2024.
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When Joe Biden and Kamala Harris held their first joint campaign event of 2024 last month in northern Virginia, they left no doubt that codifying abortion rights would be central to the president’s reelection bid. With the rally timed to honor what would have been the 51st anniversary of Roe v. Wade, Biden stood under a large “Restore Roe” sign and beside supporters holding smaller posters to “Defend Choice.”

“We need the protections of Roe v. Wade in every state. And we can do it. You can do it,” Biden stressed at the event. “Give me a Democratic House of Representatives and give me a bigger — a bigger Democratic Senate, and we will pass a new law restoring the protections of Roe v. Wade, and I will sign it immediately.”

In subsequent campaign blasts, the Biden-Harris team reiterated the Roe message. “A vote for Joe Biden and Kamala Harris is a vote to restore Roe,” said Julie Chávez Rodriguez, Biden’s campaign manager. “It’s simple,” the president tweeted to his nearly 34 million followers, under a graphic calling to “Restore the Protections of Roe v. Wade Once and For All.”

After the 2022 and 2023 election cycles, it may not be surprising that Biden is running on an abortion rights platform. What’s new, though, is that prominent abortion rights groups are biting their tongues about Roe and “pro-choice” messaging they disdain and have been trying to steer politicians away from.

In the weeks and months following the June 2022 Dobbs v. Jackson decision, it was more common to hear influential leaders within the abortion rights movement talk about the necessity of going beyond Roe v. Wade, not going back to it. The old legal standard, they argued, was never good enough, and left too many people without access to the reproductive healthcare they needed.

When a bipartisan group of lawmakers introduced a bill in summer 2022 to codify the legal protections that existed under Roe just before the Dobbs decision was issued, a coalition of reproductive rights groups came out quickly against it. Activists instead had their eyes set on the Women’s Health Protection Act, a more sweeping federal bill that would not only restore the pre-Dobbs status quo but also ban most state-level restrictions as well as religious exemptions for health care providers. (WHPA passed the House in 2021 but failed twice in the Senate.)

The groups’ opposition to anything incremental meant a more moderate, compromise effort to protect abortion rights in Congress was never seriously attempted after Roe.

The hope to go beyond Roe hasn’t disappeared. Bolstered by decisive ballot measures to protect abortion rights over the last 18 months, election wins for Democrats who campaigned heavily on reproductive freedom, and surveys that suggest voters have grown even more supportive of abortion rights since Roe’s repeal, many activists have pressed Democrats to avoid using “Roe” language at all, and even steer clear of popular “pro-choice” messaging they believe helped normalize restricting abortion over the years.

Yet with the 2024 election now closer and stakes on abortion access even higher, reproductive rights groups have decided to swallow their concerns and enthusiastically endorse the president’s reelection strategy. Vox reached out to a dozen abortion rights groups, and while many offered statements about the need to do more to protect abortion access, no organization went so far as to say they disagreed with the president on his call to restore Roe, or explicitly object to his language.

Most groups handled the tension by saying they supported codifying “real protections” that restore the “original promise” of Roe — even if the restoration of Roe could mean restoring the legal rights available before Dobbs.

“Planned Parenthood Action Fund’s long-term vision includes short-term strategies, and it’s very simple,” Alexis McGill Johnson, the president and CEO of Planned Parenthood Action Fund, told Vox. “This November, voters will have to decide between an administration that continues to work with us in the fight for freedom or an administration that caused our current public health crisis and will go further with a national abortion ban. We have a very clear choice between holding the line or descending further into what will be irreparable chaos and confusion.”

Planned Parenthood endorsed Biden’s reelection bid last June and recently published a glowing review of the administration’s record on abortion access. “You can be certain that we are fighting for more than Roe v. Wade,” McGill Johnson told me.

“We absolutely need to restore the protections of Roe v. Wade, and so much more,” said Katie O’Connor, the National Women’s Law Center’s director of federal abortion policy. “We are proud to have endorsed President Biden, and pleased he has committed to signing a bill that would lock the federal right to abortion into law,” Mini Timmaraju, president and CEO of Reproductive Freedom for All, added.

“Restore Roe” is Biden’s politics, not his policy

Biden’s campaign and surrogates are quick to point out that the president has already taken steps to protect abortion rights that go beyond the standards of Roe v. Wade. He’s on record supporting the Women’s Health Protection Act, and his administration has expanded access to abortion pills via telemedicine and at pharmacies.

So abortion rights groups and their congressional allies looking to pass stronger protections have decided to tolerate the president’s Roe messaging, trusting his team will do more if reelected, despite what he’s saying publicly now to voters.

“I support President Biden’s campaign message to restore Roe and his administration’s actions to defend abortion access,” Democratic Sen. Elizabeth Warren told me, drawing a distinction between his campaign rhetoric and his executive policies.

Whether voters know that “restoring Roe” is not the president’s end goal for abortion policy, though, is less clear. He’s never specifically articulated that fact, and his surrogates are wary to do so on the record, either. They suggest, rather, that a person should be able to infer the president’s policy goals based on a close reading of his administration’s record.

The Biden campaign, for its part, wants to keep the conversation stationed on friendly political ground — where codifying or restoring Roe simply means legalizing or protecting abortion rights. This is safer territory, since most Americans believe abortion should be legal in all or most cases and that overturning Roe v. Wade was a mistake. However, when one starts drilling down into the details about specific limits or restrictions, public opinion becomes murkier and more complex.

Where things get tricky is that Biden has not just praised Roe as a shorthand for legal abortion rights. He also continues to praise the specifics of the Supreme Court decision itself.

“It was a decision on a complex matter that drew a careful balance between a woman’s right to choose earlier in her pregnancy and the state’s ability to regulate later in her pregnancy,” the president said when the Dobbs ruling came down. “A decision with broad national consensus that most Americans of faiths and backgrounds found acceptable.”

Even at this recent Virginia campaign event in January the president went so far as to say, “I believe Roe v. Wade got it right, and so do a majority of Americans.”

This tendency to try and have it both ways on Roe has been frustrating for anti-abortion groups, as they point out the administration will praise the Supreme Court decision that endorsed limits and regulations but won’t say today which, if any, limits they’d now support.

For example, last fall, when Harris was asked if there should be any limits on the right to an abortion, said at least five times that “we need to restore the protections of Roe v. Wade” but dodged clarifying what she meant by that in practice.

Some Democratic political strategists say this waffling is simply necessary to get through November, to avoid Republicans spreading the lie that third-trimester abortions will become more common if Biden is reelected. Recently the Republican National Committee claimed in a press release that Biden supports “abortion-on-demand up until the moment of birth and after.”

The GOP also tried to attack Democrats in Virginia for supporting abortion “up until birth” in the recent 2023 election cycle, but voters didn’t seem to buy it. While Americans do tend to be more uncomfortable with third-trimester abortions, they also seem to understand they are extremely rare, and are typically associated with fetal anomalies, threats to a mother’s life, and barriers to care that delay access to the procedure.

Abortion rights groups still plan to push for more than Roe

As of now, the two major bills to codify abortion rights on the federal level are the Women’s Health Protection Act and the Reproductive Freedom for All Act, which would legalize abortion before fetal viability and permit so-called conscience protections for health care providers who oppose abortion.

When I asked a dozen abortion rights groups if they’d support codifying reproductive rights in legislation if the proposed federal bill did not go as far as the Women’s Health Protection Act, most organizations demurred or declined to answer directly. Only Catholics for Choice offered a clear affirmative statement that they’d be willing to consider any bill that allows a pregnant person to choose abortion. “This is not a time to make good legislation the enemy of the perfect,” president Jamie Manson told me.

A spokesperson for Democratic Sen. Tim Kaine, one of the lead sponsors of the Reproductive Freedom for All Act, told Vox that he remains focused on passing his bill to codify “the essential holdings of Roe and related cases to protect reproductive freedom and access to contraception.” In a press interview following Biden’s Virginia campaign event, Kaine stressed his bill is the only bipartisan one pending in Congress now to restore Roe as a statutory protection.

Despite his campaign mantra to restore Roe, the Biden campaign declined to comment on whether the president would sign the Reproductive Freedom for All Act if it passed Congress.

Democratic Sen. Tina Smith suggested lawmakers would be open to different pieces of legislation to protect abortion rights. “Our goal is to restore women’s reproductive freedoms,” she told me. “If that’s the Women’s Health Protection Act or something else remains to be seen, but that’s where I stand.”