Tag Archives: abortion

Access to abortion pills has grown since Dobbs

Originally published in Vox on December 27, 2023.
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Eighteen months after the Dobbs v. Jackson decision that overturned the constitutional right to abortion, and with a new Supreme Court challenge pending against the abortion medication mifepristone, confusion abounds about access to reproductive health care in America.

Since the June 2022 decision, abortion rates in states with restrictions have plummeted, and researchers estimated last month that the Dobbs decision led to “approximately 32,000 additional annual births resulting from bans.” Journalists profiled women who carried to term since Dobbs because they couldn’t afford to travel out of their restrictive state.

The total number of abortions in the US, however, has increased since the overturn of Roe v. Wade, driven by more people ending pregnancies in states that have laws friendly to abortion care. And often lost in this conversation is the fact that access to medication abortion has actually expanded in significant ways since the overturn of Roe v. Wade, both in terms of lower costs and avenues to obtain the pills quickly. The problem is many people who would be able to take advantage don’t know about it.

Taking a combination of mifepristone and misoprostol within the first 12 weeks of a pregnancy was already the most common method for abortion in the United States before the Dobbs decision, partly due to its safety record, its lower cost, diminished access to in-person care, and greater opportunities for privacy. The popularity of medication abortion has only grown since then: A poll released in March found majorities of Americans support keeping medication abortion legal and allowing women to use it at home to end an early-stage pregnancy. Another survey found 59 percent of voters disapprove of overturning the FDA’s approval of abortion medication, including 72 percent of Democrats, 65 percent of independents, and 40 percent of Republicans.

A June report from the Society of Family Planning found abortion via telemedicine “increased by 85 percent compared to the pre-Dobbs period, going from comprising 5 percent of all abortions to 9 percent.” And this is likely an understatement, Dana Northcraft, the founding director of Reproductive Health Initiative for Telehealth Equity and Solutions, told Vox. “That number does not include telehealth visits by providers who also do brick-and-mortar visits, [and] it does not include self-managed abortions outside of the formal medical system,” she said.

Getting the word out about medication abortion has been difficult for activists, especially with headline-grabbing news stories about new efforts to restrict the pills and punish those seeking to bypass state bans. In the early months following the Dobbs decision, if you lived in a state that banned abortion, your best bet was probably ordering pills from overseas, via the reproductive health care nonprofit Aid Access, even though their shipments could take two to three weeks.

Today, though, providers and new organizations ship pills directly from the US to pregnant people living in more restrictive states, dramatically reducing the amount of time it takes to send the medication through the mail. International volunteer networks have also expanded to help women end their pregnancies, and campaigns to destigmatize misoprostol-only abortions, a common method used around the world, have accelerated.

“We’re trying to shout this all from the rooftop,” Elisa Wells, the cofounder of Plan C, told Vox. “People are worried and there’s a lot of questions out there — is this all legit? Are the pills actually going to arrive? And we’re trying to say yes, these really are real routes of access.”

How “shield laws” have transformed the distribution of abortion pills

One of the biggest expansions to access since Dobbs is via broader access to telehealth abortion care in the US, even for those living in states with bans. Telehealth abortion care means a patient can consult virtually with a provider, either on an app or in a phone call or videoconference. Following that consultation, the provider would fill a prescription for the medication, and it would be delivered via mail.

Efforts to expand telehealth abortion care existed prior to the overturn of Roe v. Wade. Over the objections of groups like the ACLU and the American Congress of Obstetricians and Gynecologists, the Food and Drug Administration had long barred doctors from prescribing mifepristone without an in-person health care visit first. The Biden administration eased up on this rule during the pandemic, and in December 2021 the FDA permanently lifted its restriction on telemedicine for mifepristone. (State-level restrictions on abortion telemedicine still exist.)

“I think Dobbs just lit a fire under the innovations that were already underway,” Kirsten Moore, the director of the Expanding Medication Abortion Access project, told Vox. “[Telemedicine] was already happening during the pandemic and then in the post-Dobbs world everyone started thinking, ‘Oh wait, this is what we’ve got to do.’”

One major facilitator of expanded telemedicine is the profusion of new so-called “shield laws” that would protect blue-state abortion providers who send pills to people living in states where abortion is illegal. Today, six states — New York, Massachusetts, Vermont, Washington, Colorado, and California — have such telemedicine abortion shield laws, though not all have taken effect (California’s won’t until January 1). Julie Kay, the co-founder of the Abortion Coalition for Telemedicine, told Vox these laws are already facilitating the distribution of pills to 6,000 patients per month in states with bans. One major advantage is that shipping pills from a US state with a shield law is much faster than shipping pills from overseas. The medication can arrive in days, rather than weeks.

Kay said the effort to pass shield laws was led by the medical community, not traditional pro-choice advocacy groups. “Our focus has really been on serving marginalized communities in red states that have been denied abortion, West Virginia all the way through Texas,” she said. “A lot of people living there are not able to travel but do not know they have another option.”

While these laws have yet to be tested in court, providers expect legal challenges eventually and have been taking steps to protect themselves, like avoiding travel to states with abortion bans in case a prosecutor tries to arrest them for violating their criminal statute.

Some providers living in states with shield laws are interested in stocking and shipping the medication themselves. Others say they’d be interested if they could send prescriptions to a pharmacy that would handle the mailing for them. Starting in the new year, one online pharmacy based in California, Honeybee Health, aims to help abortion providers living in states like New York and Massachusetts serve more patients nationally.

“We think people, including the media, are less familiar with the idea that you can have an abortion by mail and that the service of telehealth abortion is available in every single state — even those with bans,” said Wells, of Plan C. “That didn’t exist before Dobbs. That is the big change that’s happened. People find it unbelievable, but it’s also fantastic.”

Wells says the big shift really happened in June 2023, when Aid Access became the first organization to start leveraging the new shield laws in the US. No longer would a pregnant person in Texas or Oklahoma searching for Aid Access online be routed to an abortion provider in Europe or need to wait for a pharmacist in India to mail them medication. Shortly thereafter, a new US organization, Abuzz, launched to provide telemedicine abortion to 30 states, followed in September by the Massachusetts Medication Abortion Access Project, which also utilizes shield laws for telemedicine care.

The e-commerce marketplace for abortion medication has expanded, and the cost for pills has fallen dramatically

Outside of telemedicine options, there are over two dozen e-commerce websites that sell and ship medication abortion to the US. This international supply chain has grown significantly since Dobbs and most of these sites do not require prescriptions and do not require people to upload their IDs or have medical consultations. Plan C has vetted 26 of these sites, including testing their pills to ensure they’re “real products of acceptable quality.”

Seven of the sites Plan C has vetted offer pills for prices ranging from $42 to $47, with delivery times between two and nine days. The sites are typically selling generic medications originating from India, with the help of US-based shippers.

One unexpected development this year was that many of these e-commerce websites ultimately dropped their prices by hundreds of dollars, in an effort to get higher placement on Plan C’s website.

Another pharmaceutical provider — ProgressiveRx — provides a prescription, pills, and a telehealth consultation all for $25, though its shipments from India typically take three to four weeks to arrive. Wells says ProgressiveRx is a great option for women living in restrictive states to stock up on pills in advance. (Mifepristone has a shelf life of about five years, and misoprostol about two years.)

The New York Times estimated in April that international suppliers were likely to provide abortion pills to about 100,000 Americans in the year after Dobbs was decided, or “enough pills to cover about 10 percent of the country’s annual abortions.” Anti-abortion groups have acknowledged the difficulty in stopping the flow of abortion drugs into the US.

Volunteer distribution networks have expanded

Community support groups, also known as “companion networks,” have grown since the overturn of Roe v. Wade and now actively provide free abortion pills to people living in states with bans on reproductive health care. These groups, some of which can be found on sites like Plan C and Red State Access, mail medication abortion and offer doula support.

“You communicate with these groups via [encrypted messaging apps like] Signal, and you don’t need a credit card or a bank account, which can be especially important for young people who might not have those resources,” Wells said. “We know the volunteer networks well and we have no hesitation in recommending them.”

Some of the volunteer companion networks are aided by activists in Mexico. The most prominent Mexican activist group is Las Libres, which was founded in 2000 to serve Mexican women. Abortion access in Mexico has improved, though, and in 2021 Las Libres pivoted to helping Texas women who were newly subject to the state’s six-week ban. The group’s US focus expanded further after Dobbs, and after Mexico’s Supreme Court decriminalized abortion nationwide in September 2023. In 2022 alone, Las Libres helped terminate roughly 20,000 pregnancies in the United States.

How medication abortion access could change in 2024

Earlier this month, the US Supreme Court announced it would hear a challenge to mifepristone, the abortion medication that anti-abortion groups claim was unlawfully approved back in 2000.

While abortion advocates doubt the justices will go so far as to pull mifepristone off the market, as a federal judge in Texas attempted to do earlier in 2023, they are bracing for the possibility that the court might reimpose medically unnecessary restrictions on access, like bans on prescribing mifepristone via telemedicine.

Even if that happens, though, most of the aforementioned options for accessing medication abortion would remain intact. It’s not clear if the FDA would even abide by such a Supreme Court ruling, but if it did, providers using shield laws could still legally ship misoprostol to patients in banned states.

“A Supreme Court ruling wouldn’t affect the community-based networks, ProgressiveRx, or the e-commerce websites that sell pills at all, and so there would still be ways of getting mifepristone and misoprostol in the mail,” Wells said. “The Supreme Court could affect services like Aid Access and Abuzz, but they could also switch to misoprostol-only abortions and that’s what they’re planning to do.”

While not FDA-approved, misoprostol-only abortion is a method backed by the World Health Organization, and a common way of ending pregnancies around the world. The National Abortion Federation, in its clinical guidelines, says that “where mifepristone is either not legally available or inaccessible, misoprostol-alone regimens may be offered.”

Kay, of the Abortion Coalition for Telemedicine, told Vox that some abortion providers will probably continue to ship mifepristone even if the Supreme Court reinstates the ban on mailing the pills, given that the combination of mifepristone and misoprostol is slightly more effective than misoprostol-only abortions. (Both options are considered safe for patients, but studies show using just misoprostol is effective at ending pregnancy about 88 to 93 percent of the time, versus 95 to nearly 100 percent for the two-drug regimen.)

A bigger threat to medication abortion access than the Supreme Court may be the election of a Republican to the White House next November, who would control appointments to key federal enforcement agencies like the Justice Department, the Department of Health and Human Services, the US Postal Service, and the FDA.

Anti-abortion groups have already declared medication abortion their top priority if Donald Trump or another Republican is reelected. While GOP lawmakers in Congress might not have enough votes for a federal abortion ban, activists see new executive orders as an alternative way to restrict pill distribution. Anti-abortion activists say they intend to track the views of potential GOP appointees, rather than press Republican presidential candidates on their specific regulatory plans.

Moore, of Expanding Medication Abortion Access, said one risk is that the government will raise the threats of criminal or financial penalties against providers, dissuading more clinicians from offering care.

How abortion rights activists are working to further improve access to pills

Though the cost of medication abortion has dropped substantially since Dobbs, the price is still out of reach for some who need it, and activists are working to help more pregnant people cover the cost of their care.

Kay told Vox the Abortion Coalition for Telemedicine is working on a project dedicated to funding abortion pills for those who can’t afford to pay, something the organization hopes to launch in early 2024.

Moore said leaders need to do more to support women in the two or three days after they take the abortion drugs. “Medication abortion can be an ongoing process for 24 to 48 hours, and we can get people their pills really quickly but helping them manage the process does require more time and investment,” she said. “To be honest, I think we’re still building out the infrastructure for that part of the care.”

Even as activists work to expand access, anti-abortion lawmakers plan to continue their efforts to restrict access to medication abortion, including by exploring new strategies banning website visits to Aid Access and Plan C and making health care providers newly liable for disposing of aborted fetal tissue. Some lawmakers want to test the limits of their extraterritorial powers, and are exploring how they might retaliate against providers in other states, even those operating under shield laws.

Despite these threats, the odds of shutting down all these avenues for abortion medication is low, and the bigger challenge is really helping more people learn about their evolving options. Sometimes that means activists battling big tech platforms over what abortion-related content they’re censoring, and sometimes it means media outlets doing a better job of conveying new information to the public.

Northcraft, of Reproductive Health Initiative for Telehealth Equity and Solutions, added that while telehealth can alleviate many of the expenses associated with getting an abortion — such as travel costs, taking time off work, and lining up child care — there is still more work needed to ensure equity, like ensuring that platforms and providers communicate in multiple languages.

“At the end of the day medication abortion is safe, effective, and what people want,” Kay said. “And it’s going to be available by licensed medical professionals, by people who are mission-driven but not medically certified, or through a for-profit thing on the world wide web. We know it’s not going away.”

Republicans can’t sugarcoat their losses on abortion rights anymore

Originally published in Vox on November 8, 2023.

Even before Tuesday’s elections, many progressives insisted the question of whether protecting abortion rights wins elections was already asked and answered. Democrats made abortion rights the centerpiece of their campaign advertising during the 2022 midterms, a cycle where Democrats outperformed expectations, kept control of the US Senate, and staved off a red wave. Polls last year also found abortion rights to be a significantly motivating issue for both independent and Democratic voters.

Abortion rights ballot measures won in all six states where they appeared in 2022, including states like Montana, Kentucky, and Kansas that otherwise elected Republican candidates. Democrats have been winning in special elections where they ran on abortion rights, and surveys suggested voters have grown even more supportive of abortion rights since the repeal of Roe v. Wade in June 2022.

Anti-abortion groups argued in turn that liberals were mistaking correlation for causation; they maintained that confidence in abortion rights messaging was misplaced, and voters would ultimately punish Democrats for their maximalist positions. They pointed out that Democrats tried and failed to unseat anti-abortion governors in the midterms, and applauded winning federal candidates who “went on offense” on abortion, like Sen. Marco Rubio and Ohio Sen. J.D. Vance. The lost referendums, anti-abortion groups insisted, stemmed largely from Republican leaders failing to campaign hard enough and from being outspent, something they promised to never let happen again.

The polling on abortion rights, meanwhile, could be complicated and seem contradictory: Voters sometimes express support for second- and third-trimester bans while signaling strong opposition to restricting access to abortion.

The 2023 election cycle represented a big test: Were abortion rights activists right? Or were anti-abortion leaders correct that the earlier post-Roe losses stemmed from insufficient investment and mealy-mouthed campaigning?

A decisive 13-point victory for protecting abortion rights in red Ohio, wins for Democrats in the Virginia legislature where GOP candidates campaigned on rolling back abortion access to 15 weeks, and the decisive reelection of Kentucky Democratic Gov. Andy Beshear, who made protecting abortion rights in his red state central to his campaign, provide the clearest evidence to date that voters of all political persuasions do not support the nationwide attack on reproductive freedom and are voting accordingly.

Anti-abortion leaders tested a host of new tactics this cycle — from rebranding abortion bans as “limits” to claiming the Ohio abortion rights ballot measure was really about curtailing parents’ rights. None of them worked. Republican strategists had been banking on November 7 providing them with proof that voters were sick of Democrats talking about abortion. Virginia was supposed to be a proof of concept that would let Republicans run on a “consensus” position on 15-week bans next year while changing the subject to other topics like crime and immigration.

So Tuesday’s results really were a resounding victory for Democrats and abortion rights supporters — but there are still some caveats and reasons for caution in 2024.

How abortion rights won in Ohio

Anti-abortion leaders recognized how important a win in Ohio would be to changing the narrative ahead of 2024. “A win here would show those other states that will have these ballot measures in the years to come, ‘Hey, these battles can be won,’” Peter Range, the executive director of Ohio Right to Life, told the 19th News in October. The anti-abortion movement threw everything they had at the campaign and still fell far short.

Instead, last night 57 percent of Ohio voters cast their ballot in favor of the constitutional amendment to codify abortion access, despite a significant array of obstacles in a solidly Republican state where Republican elected officials had come out uniformly against the measure.

“Generally speaking, ballot measures in Ohio don’t tend to win,” said Jonathan Robinson, the director of research at Catalist, a liberal voter data analytics firm.

Passing affirmative ballot measures is even harder. In the other conservative states where ballot measures won, abortion rights campaigners organized voters against anti-abortion proposals. Political scientists find it can be easier to be on the “no” side of ballot measure campaigns, since voters have a bias toward maintaining the status quo.

“The reality is Ohio is among the tougher states that we have worked in,” said Joey Teitelbaum, a pollster involved with the Ohio abortion rights campaign, who also worked on winning ballot measures in Colorado, Kansas, and Kentucky. “We stayed focused on a broad values-based message that went beyond partisan politics.”

Though polls indicated Ohio voters were broadly supportive of the proposed amendment, abortion rights advocates were dealing with new hurdles, including an expensive August special election that sought to raise the ballot measure threshold to 60 percent, voter roll purges led by the anti-abortion secretary of state, a misleading intervention from the state’s Republican attorney, and vocal campaigning from the state’s Republican Gov. Mike DeWine, who urged Ohioans to vote no in a TV ad.

The Ohio Ballot Board also drafted its own summary language of the proposed ballot measure, using more politically objectionable terms like “unborn child” instead of “fetus” and refusing to state that the amendment would protect not just access to abortion but also to contraception, miscarriage care, fertility treatment, and continuing pregnancy. Researchers know that the specific language that appears on a ballot can have a significant impact on how voters vote, and a poll released in late October found support for the amendment dropped considerably when voters were presented with the edited language.

“I have never encountered such complete opposition by the state government,” said Ashley All, who served as communications director for the winning pro-abortion rights ballot measure campaign in Kansas and has since consulted on other post-Roe ballot referendums.

Anti-abortion advocates raised millions more dollars than they had in previous ballot measure campaigns, and worked to cast the Ohio amendment as an “anti-parent” measure that would effectively create a new right to gender-affirming surgery for minors. Legal scholars said the fear-mongering about parental consent was unjustified, given Ohio case law and the Republican-controlled state Supreme Court.​

That abortion rights won so decisively against all these odds — and that so many Trump voters proved willing to cross party lines to vote in favor of the amendment — is a sobering result that anti-abortion leaders will struggle to dismiss. For now, the Susan B. Anthony Pro-Life America group is saying it lost because voters incorrectly believed pregnant patients could be denied life-saving medical care. But even in states with exceptions to abortion bans, doctors have been denying or delaying care, fearing funding cuts or criminal prosecution.

How abortion rights won in Virginia

Though Virginians were not casting votes on a ballot measure, it was no secret that the Virginia legislative elections were largely being fought over abortion.

“It almost feels like we’re running a single-issue campaign on this one,” J. Miles Coleman, of the UVA Center for Politics, said last week. Among women voters, who make up more than half of Virginia’s election, 70 percent rated abortion as a “very important” issue, up 47 percent from 2019.

All 140 seats in the Virginia General Assembly were up for grabs, and Democrats not only retained control of the state Senate but flipped control of the Virginia House.

Youngkin and anti-abortion groups bet that if they could win in Virginia by running emphatically on a 15-week abortion ban, something they cast as a “reasonable” and “consensus” position, then they could prove to Republicans nationwide that abortion need not be a political loser for their party. (The ban, which they called a “limit,” also would have exceptions for rape, incest, and the life of the mother.) They also hoped that staking out this position would allow them to more easily change the subject to topics they had advantages on, like crime and the economy.

Prior to the fall of Roe, national polls showed broad support for restricting abortion after 15 weeks, but since the Dobbs decision, voters have been signaling more opposition to the idea. A poll released in mid-October from Christopher Newport University found 54 percent of Virginians opposed the idea of a 15-week ban, and another October survey from the Washington Post-Schar School found 47 percent opposed and 46 percent approved.

Another way to understand the question in Virginia is whether voters would support lawmakers cutting short the window of legal abortion by 12 weeks, since abortion is currently permitted up to 26 weeks and 6 days of a pregnancy in the state.

Voters, though, had good reason to be suspicious Virginia Republicans really would stop at 15 weeks. In Florida, Republicans passed a 15-week ban on abortion in 2022, only to turn around and pass a six-week ban in 2023. Other GOP-led states like South Carolina, Georgia, and Ohio have passed six-week bans.

Multiple videos also emerged of Virginia Republicans admitting they’d likely push for more than they’ve publicly let on. In 2021, an activist secretly recorded Youngkin saying he’d go “on offense” if elected but needed to speak minimally about the topic during campaign season. Two months ago videos surfaced of a House of Delegates candidate saying he’d support a “100 percent” and “total” ban on abortion, and more recently a video of a candidate in a Virginia Senate race showed her saying she’d be interested in pushing beyond a 15-week ban.

A Washington Post-Schar School poll from October found that 51 percent of registered Virginia voters trusted Democrats to handle abortion, compared to 34 percent who trust Republicans.

There are real grounds for abortion rights optimism in 2024

The news out of Ohio is auspicious for those organizing abortion rights ballot measures next year in Arizona, Nevada, Florida, South Dakota, Nebraska, and Colorado. Abortion rights have had a 7-0 winning streak on the ballot since Roe v. Wade was overturned, and Republicans’ fear-mongering rhetoric about parents’ rights and abortion “up until birth” seemed to have failed. While Americans tend to be more uncomfortable with abortions later in pregnancy, voters seem to understand they are extremely rare, and typically associated with fetal anomalies, threats to a mother’s life, and barriers to care that delay access to the procedure.

Evidence continues to mount that voters are willing to cross party lines when it comes to protecting access to reproductive health care. If abortion rights campaigners can continue to frame the issue in a nonpartisan way, their odds of success in the next round of ballot measures look good. Democratic Gov. Andy Beshear’s strong reelection in Kentucky is also an encouraging signal that Democrats can campaign openly on abortion rights in red states and still win.

It’s hard to overstate how much the loss in Virginia complicates’ Republicans’ 2024 campaign plans. Virginia was supposed to show that Republicans could cast Democrats as extremists, proactively pursue reductions in abortion access, and still win, even among Biden-leaning voters. The GOP wanted to show Republicans could “neutralize” the abortion issue, so that swing voters would feel more comfortable voting on other topics they trusted Republicans on. Youngkin insisted voters are “ready to move on and talk about topics besides abortion.”

The fact that Republicans failed so spectacularly doesn’t mean Republicans won’t try this strategy again next year, but it does represent a rather clarifying result — and one that should make GOP strategists pretty nervous, especially given that most voters think Republicans want to ban abortion in all or most cases.

How things could still go poorly for abortion rights in 2024

While things have gone well for abortion rights campaigners thus far, most will admit they were certainly not sure things would play out as they did. And, as anti-abortion leaders are quick to point out, Democrats tried and failed to unseat anti-abortion governors like Brian Kemp in Georgia, Kim Reynolds in Iowa, Mike DeWine in Ohio, and Ron DeSantis in Florida last year, showing that it’s not dispositive that politicians will pay a price for restricting access to abortion.

“In the midterms, yes, abortion mattered in certain places, and democracy issues mattered on certain races. But not all of them,” Ashley All told Vox. “Florida voted exactly as Florida does. Political observers and pundits want to make blanket statements about how things will impact an election, but everyone who works on campaigns knows it doesn’t work like that.”

Another concern is that Youngkin’s prediction was just premature and that voters will in fact grow more tired of hearing about attacks on abortion rights the further out from Dobbs the country gets. Republicans bet wrongly on that happening in 2022 and 2023, but experts admit it’s hard to know what will be animating voters a year from now, especially given how exhausted the electorate seems to be these days.

“Generally people seem a little burnt out,” said Robinson, of Catalist. “The level of political donations for Democrats and Republicans is down a lot, which suggests a sag in interest in politics. Interest in the Republican presidential primary is really low.” Though turnout on November 7 was high, the abortion rights measure in Ohio received nearly as many votes as Republican Sen. J.D. Vance did in 2022.

Reproductive rights campaigners also say the public should not underestimate how tough a fight they faced this year in Ohio compared to the previous six ballot measure campaigns in 2022. Anti-abortion politicians are likely to continue their efforts to curb access to the ballot, and invest heavily in TV and digital advertising aimed at confusing voters. This year abortion rights activists benefited from Ohio being the only ballot measure campaign in the country, helping them to raise three times as much money as their opponents, with most money coming from out of state.

Next year, when there are more expensive ballot measures competing for both media attention and political donations, on top of a surely consuming presidential contest and a bevy of congressional and gubernatorial elections, advocates say the fundraising landscape for abortion rights referendums may be much more difficult.

The anti-abortion movement insists everything is really fine

Originally published at Vox on August 24, 2023.
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The anti-abortion movement is at a political crossroads.

Last year, abortion rights won in all six states with abortion ballot measures, including in red states like Kentucky and Montana that otherwise elected Republican candidates. Earlier this month, activists suffered yet another defeat when Ohio voters cast ballots decisively against a referendum that would have made it harder for constitutional amendments, including an upcoming vote this November on abortion rights, to pass in the future. Abortion was not on the ballot, but anti-abortion groups campaigned heavily in favor of the Ohio measure, and they lost.

Even the Republican presidential primary, which the anti-abortion movement had been planning to dominate, has been something of a mixed bag, and there are signs that the movement’s influence is wavering. During Wednesday night’s GOP debate, Fox News moderator Martha MacCallum argued that “abortion has been a losing issue for Republicans since the Dobbs decision.” A recent New York Times/Siena poll shows that more than a third of Republican primary voters think abortion should be legal all or most of the time, and in a CBS poll this week, most didn’t think it was very important for Republican candidates to talk during the debate about their plans to restrict abortion.

Some candidates, including former Vice President Mike Pence, are still eagerly courting support from the movement, but others appear less willing to take their campaign cues from those anti-abortion organizations.

Donald Trump, for example, has resisted calls from the leading activist group, Susan B. Anthony Pro-Life America, to endorse a national 15-week ban on abortion. He’s also refused to say if he supports the type of six-week abortion ban that Gov. Ron DeSantis signed in Florida. Trump would say, however, that “many people within the pro-life movement feel that that was too harsh.”

And when DeSantis was dismissive of federal abortion restrictions in late July, saying he believed the anti-abortion movement would see more success from states and local communities, SBA Pro-Life America criticized his stance as “unacceptable.” DeSantis’s campaign didn’t seem to care, countering that the governor “does not kowtow to D.C. interest groups.”

Does that mean the anti-abortion movement is planning to rethink its own aggressive post-Roe strategy of trying to limit abortion as much as possible in as many places as possible? For now, the answer is broadly no. Instead, leaders argue that any losses they’ve suffered over the last year have not been because their agenda is unpopular, but because it hasn’t been pursued boldly and strategically enough. If anything, they say, winning will require an even stronger commitment to restricting abortion.

GOP presidential candidates are divided on federal abortion bans

Leading groups opposing abortion rights are divided on what they want to hear from federal candidates.

SBA Pro-Life America has said it will not support anyone who does not express at least a commitment to restricting abortion at the federal level after 15 weeks. Meanwhile Students for Life made clear that they oppose such a 15-week litmus test, given that more than 90 percent of abortions occur within the first 13 weeks. Instead, they asked each candidate to lay out their proactive vision for a post-Roe America, and emphasized that their own blueprint includes granting legal protections to unborn children, defunding Planned Parenthood, banning the distribution of medication abortion by mail, and reimposing other restrictions on abortion pills that were relaxed under the Biden administration.

During the first GOP primary debate, however, most candidates declined to do any of these things, and appeared divided on whether the federal government should limit abortion at all. DeSantis dodged a question on whether he’d support a six-week ban, former South Carolina Gov. Nikki Haley stressed the fact that there’s little chance of getting something through Congress, and North Dakota Gov. Doug Burgum claimed a federal ban would violate the 10th Amendment of the US Constitution. Of the eight candidates on stage, only Pence and South Carolina Sen. Tim Scott backed a 15-week restriction.

Yet while some GOP political consultants quietly worry about electoral backlash to abortion bans that voters consider too extreme, anti-abortion groups have urged candidates to stay the course, and to champion the post-Roe successes the movement has achieved so far.

“A year after Dobbs, 25 states have put pro-life protections into law — half the country,” SBA Pro-Life America stated after the Ohio election. Rejecting the idea that abortion rights were helpful to Democrats in 2022, they touted the midterm wins of Florida Sen. Marco Rubio, North Carolina Sen. Ted Budd, and Ohio Sen. J.D. Vance. Catherine Glenn Foster, president of Americans United for Life, offered a similar rosy post-midterms reflection, noting that public officials who backed or enforced abortion restrictions were reelected in nearly 20 states. “Democrats didn’t crack state governor, state attorney general, or state house seats in red states that have enforced abortion limits since [Dobbs],” she argued.

The movement against abortion rights isn’t admitting defeat

While the attempt to make it harder to pass ballot measures — known as Issue 1 — lost by 14 percentage points in Ohio, anti-abortion groups say that does not mean they’ll face a similar fate when abortion is actually on the ballot in November. The proposed Ohio amendment would restore the right to an abortion up to the point of fetal viability, and permit abortions beyond that point if a patient’s doctor deems it necessary to protect their life or health.

In their post-mortem memo, SBA Pro-Life America said they lost for two reasons: they didn’t start their campaign against Issue 1 early enough, and some voters were motivated to vote no because of concerns about democracy and other policies, like the minimum wage or legalizing marijuana. The group claims it does not see support for abortion rights as a key reason for Issue 1’s failure.

Anti-abortion groups have also blasted Republican elected officials and business leaders for not campaigning hard enough. “The silence of the establishment and business community in Ohio left a vacuum that was too large to overcome,” SBA Pro-Life America argued. “So long as the Republicans and their supporters take the ostrich strategy and bury their heads in the sand, they will lose again and again.”

Terry Schilling, leader of the conservative American Principles Project, likewise slammed GOP donors for not spending heavily enough on the Ohio election, and he blamed Republican presidential candidates and national party leaders for downplaying its importance. Another national anti-abortion group, Students for Life, made similar arguments, noting that being outspent by opponents almost 5 to 1 “certainly helped create the confusion about what was at stake.”

While groups supporting abortion rights frame the Ohio results as a clear-cut victory for their cause, election analysts caution we don’t yet fully understand who voted for Issue 1 and why, and it is possible that voters who cast their ballot against the Issue 1 referendum in August will also vote against expanding abortion restrictions in November.

Students for Life has recently launched a “3-step plan” for defeating the abortion rights amendment, largely by mobilizing youth voters. The group is arguing that voters in states like Kansas are experiencing “buyer’s remorse” for approving a state constitutional amendment for abortion rights last year, and they claim they’ll dissuade Ohioans from making the same mistake. When asked for evidence of such remorse, spokesperson Kristi Hamrick told Vox it’s based on her group’s “lived experience [and] talking with people on the ground.”

Early polls on the November amendment bode well for abortion rights supporters; one from June found nearly 60 percent of Ohioans support the idea of an amendment for reproductive freedom. But political researchers say it’s generally harder for affirmative ballot measures to pass, given what’s known as a “status quo bias.” To pass the Ohio amendment, advocates may copy the playbook from Michigan, where abortion rights activists framed their winning 2022 ballot measure around the idea of restoring the rights of Roe v. Wade — bringing back the reality Americans had known for five decades. Opponents, meanwhile, will claim activists are trying to radically expand rights.

Anti-abortion leaders are already running with this strategy, claiming that Ohio’s proposed abortion rights amendment’s language is so broad that it would create a new right to gender-affirming surgery, and therefore invalidate the state’s requirement for parental consent.

In its post-mortem memo, SBA Pro-Life America argued that advocates in Ohio must stick with “a simple message,” framing the upcoming referendum as “an attempt by ACLU to eliminate parental rights and legalize abortion on demand in the Ohio constitution.” The amendment would only permit abortions past the point of fetal viability to protect a patient’s life or health, but SBA Pro-Life America is urging advocates to claim it will “legalize unrestricted access to abortion until the moment of birth, paid for by Ohio taxpayers.”

Anti-abortion groups note that the ACLU has long opposed parental consent laws, and an ACLU Ohio lawyer in February said existing laws that conflict with a constitutional amendment “should not be enforced.” Still, Ohio case law generally requires parental consent for youth medical care, and the amendment could only affect parental consent laws if someone were to successfully challenge the rules in court as unconstitutional. Given that Ohio’s state Supreme Court is controlled by Republicans, legal experts think a more sweeping interpretation of the abortion rights measure is unlikely. Andrew Everett, an ACLU spokesperson, told Vox in July they “have no plans to challenge parental consent laws in Ohio.”

Even the most unapologetic anti-abortion groups recognize they need to work on the movement’s image

While leading national groups insist there’s no real proof candidates should back away from abortion restrictions, activists are talking more about the need to speak more compassionately to the needs of mothers and children — driven partly by media coverage showing pregnant women and new mothers have suffered under new anti-abortion laws.

SBA Pro-Life America urged lawmakers to support legislation that requires child support payments to begin when a fetus is in the womb, and to expand the child tax credit and parental leave support. Students for Life similarly emphasized the need to better support pregnant moms and parents on campuses. Route Fifty reported that at least four states have approved new tax exemptions for pregnant people and anti-abortion centers, and nearly a dozen more are considering them.

A few dissenting voices in the anti-abortion movement have recently urged more compromise. Schilling, of the American Principles Project, said candidates should stick with 15-week bans that allow for exceptions for rape, incest, and protecting the life of the mother. “Abortion limits need to be reasonable and popular,” he told Politico. “15 weeks, build a genuine culture of life, revisit,” echoed Duncan Braid, a staffer at the conservative think tank American Compass.

But for now these are minority voices, and the anti-abortion movement is broadly urging lawmakers to get bolder, lest they meet the same electoral fate as failed Republican Senate candidates Mehmet Oz in Pennsylvania and Adam Laxalt in Nevada — who SBA Pro-Life America claim ran from abortion in their midterm races and subsequently lost. “Going on offense is essential for any candidate who wants to win in 2024,” said the group’s president, Marjorie Dannenfelser, at the conclusion of Wednesday’s debate.

Republicans’ abortion bans are nothing like those in Europe

Originally published in Vox.com on June 6, 2023.
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Republicans scrambling to address mounting backlash to abortion bans have landed on what they hope they can market as a moderate political compromise: limiting abortion after 12 weeks of pregnancy.

Over the last month, Republicans in North Carolina and Nebraska have passed 12-week abortion bans, a dramatic reduction in access for states that previously allowed abortion up until 20 weeks and 22 weeks, respectively.

North Carolina’s ban would permit abortion for rape victims through 20 weeks, for life-threatening fetal anomalies through 24 weeks, and to protect the life of the mother throughout. Nebraska’s new ban would permit exceptions for rape and to save the life of the mother, but not for fatal fetal anomalies. (Health of pregnant person exceptions have been notoriously confusing for doctors in practice, who fear criminal sanctions for violating the vague statutes.)

Republican politicians are casting these new 12-week bans as “mainstream,” comparing them to even more extreme GOP-led states that have banned virtually all abortion, and pointing to other countries, particularly in Europe, that also impose gestational age limits at 12 weeks.

The rhetorical strategy of invoking other countries to justify banning abortion will sound familiar to those who followed the overturn of Roe v. Wade. In that case, Dobbs v. Jackson, Mississippi lawmakers defended their 15-week abortion ban by pointing out that most European countries have even earlier restrictions.

In the Dobbs Supreme Court hearing itself, Justice John G. Roberts claimed the proposed 15-week ban mirrors “the standard that the vast majority of other countries have.” In his majority opinion, Justice Samuel Alito cited a study published by a leading anti-abortion group that argued the US was out of step with the rest of the world in terms of abortion after 20 weeks.

The study, published by the think tank arm of the Susan B. Anthony Pro-Life America, said 47 out of 50 European nations limit “elective” abortion before 15 weeks, meaning before then doctors are not required to attest to a particular justification for the abortion.

But differences between the US and European countries are more complex than that simple comparison suggests. In practice, abortion limits in the United States are far more restrictive than what exists in most of the Western world, including in nations with gestational age limits at 12 weeks, like Germany, Denmark, Belgium, and Italy.

This distinction between “elective” abortions (or “abortion on demand,” as it’s more provocatively called) and “therapeutic” abortions, which are done for medical reasons, might seem like a key distinction between the US and Europe. But in practice, the line is much blurrier. All abortions are ultimately elective — no one is forced to end a pregnancy, even if a doctor recommends it. Plenty of elective abortions are done for therapeutic reasons.

Moreover, European countries that have 12-week limits on “elective” abortions still make it fairly easy for women to get abortions later on, with relatively broad exceptions for mental health or socioeconomic circumstances. Republicans have aggressively fought against similar exceptions, and in particular have worked to bar consideration of mental health risk — even the risk of suicide if a pregnancy continues — as a factor.

And in other ways, European countries make it easier to get an abortion than in even relatively permissive jurisdictions in the United States. Across Europe, abortion services are covered under national health insurance, meaning the cost of accessing care is a far lower barrier for pregnant people facing time constraints.

By contrast, in the US, cost is one of the biggest hurdles to ending a pregnancy. Even though more than 90 percent of abortions occur within the first 13 weeks, roughly 75 percent of all US abortion patients are low-income according to 2014 numbers, and researchers find Americans needing care in the second trimester tend to be those with less education, Black women, and women who have experienced “multiple disruptive events” in the past year, such as losing a job.

Republican lawmakers are also bucking international trends in working to aggressively restrict access to telehealth abortion care and medication abortion generally — which allows patients, especially those who live in remote and rural areas, to get the abortion services they seek on a faster timeline. Both North Carolina and Nebraska have fully banned abortion via telehealth, despite research affirming its safety and efficacy.

Across the globe, the clear trend has been to expand access to abortion, decriminalize the procedure, and loosen restrictions. While restrictive policies, including earlier gestational limits, still present barriers for international abortion care, per the Center for Reproductive Rights, nearly 60 countries have liberalized their laws and policies on abortion since 1994. Only four — the US, El Salvador, Nicaragua, and Poland — have further restricted rights.

Even with earlier gestational limits, abortion in Europe is broadly affordable and accessible. This is not the paradigm Republicans are proposing in the United States. They are fighting to keep abortion expensive, particularly for low-income patients who rely on Medicaid; to limit the reasons like mental health for which patients can access legal abortion; and to restrict access to care, all while imposing bans on telemedicine, ramping up criminal penalties for providers, and shortening the legal timeline for pregnant people to raise funds, arrange travel, and book mandatory medical appointments.

Understanding international abortion access in practice

Republicans have been eager to point to countries that restrict “elective” abortion after 12 weeks to justify the supposedly mainstream nature of their new bans. But in 21 countries across Europe, the cost of abortion care is fully paid for by federal governments, making first-trimester abortions simply easier to do. Abortions in the US can easily exceed $500 out of pocket, and only 17 states currently cover abortion under their Medicaid programs, which they must do with state funds, not federal dollars, as Congress prohibits it.

Another difference is that abortion exceptions for “health of the pregnant woman” in Europe take into account mental health, too. In Germany, for example, while abortion is permitted upon request throughout the first 12 weeks, someone can seek legal abortion through 22 weeks if it would help them “avert the danger of grave impairment to [their] physical or mental health.”

In Britain, which allows legal abortion up to 24 weeks, it’s similarly clarified that a pregnant person can access care if it’s determined that ending the pregnancy would cause less damage to the patient’s physical or mental health than continuing to carry.

“This is always granted [by doctors] under the correct assumption that continuing a pregnancy is always more dangerous than terminating, and that continuing an unwanted pregnancy is always detrimental to a person’s mental health,” said Maria Lewandowska, a reproductive and sexual health researcher at London School of Hygiene and Tropical Medicine.

Any doctor can provide this authorization, she said, and in practice, patients often get approval directly from doctors at abortion clinics. Advocates in the UK have been encouraging the government to authorize nurses and midwives to grant this permission, too.

Some countries don’t explicitly state “mental health” in their statute, but recognize that maternal health includes psychological health. The author of France’s 1975 abortion law clarified during legislative hearings that “the very term ‘health’ covers, it seems to me, the mental aspect as well as the physical aspect.” The World Health Organization’s definition of “health” includes “mental health.” In Canada, leaders make no formal distinction between physical and mental health, which Joyce Arthur, executive director of the Abortion Rights Coalition of Canada, says allows providers to “better integrate abortion care into the broader health care system.”

Meanwhile, research on the psychological harm associated with carrying unwanted pregnancies continues to mount. The Turnaway Study, a longitudinal study on the effects of unwanted pregnancy on patients’ lives, found that the mental health of women able to end unwanted pregnancies was significantly better than that of women forced to carry to term. Another report published in 2022 found that suicide is a leading cause of death for pregnant people during pregnancy and the first year following it.

Anti-abortion activists in the US, for their part, continue to dismiss these studies. “Having an abortion will not mitigate mental health issues,” said Laura Echevarria, a spokesperson for the National Right to Life Committee, which has lobbied state legislatures to exclude mental health.

In addition to providing exceptions for mental health and paying for abortion care, pregnant people in European countries can also seek legal abortion beyond their country’s 12- or 14-week limit for broad socioeconomic reasons, like feeling too young or too old to have children, feeling consumed by existing children, being a single parent, or lacking a stable housing or financial situation. The Center for Reproductive Rights counts at least 16 European countries that permit abortion on socioeconomic grounds.

In Denmark, for example, though the country has a 12-week ban on paper, it’s considered relatively feasible for residents to get approval for abortion beyond that. In 2021, 803 pregnant people applied to get an abortion in Denmark beyond 12 weeks, and 750 were approved.

Thousands of pregnant women living in countries with 12-week abortion bans travel internationally to end their pregnancies

Even with broader grounds for legal exceptions and greater financial assistance available in countries with earlier gestational age limits, first-trimester bans in Europe still force thousands of pregnant people to travel internationally every year to end their unwanted pregnancies. (A French parliamentary report from 2020 estimated that as many as 4,000 French women traveled abroad for abortion annually due to gestational limits. In 2022, French legislators extended their limit to 14 weeks.)

One study published in March looked at people who traveled from countries like Austria, Bulgaria, France, Germany, and Italy to the Netherlands or England for later abortion care. Over half of the pregnant people surveyed hadn’t learned they were even pregnant until they were at least 14 weeks along, when they had already surpassed the limits in their home countries.

The reasons participants cited for not knowing they were pregnant hold strong relevance for pregnant people in the US living in states with new 12- or six-week bans. The participants all said they would have preferred earlier abortion care but didn’t know they were pregnant due to reasons like irregular periods, lack of clear pregnancy signs, misinformation by doctors about contraception, or their gestational age.

While European passports make travel to other EU countries relatively easy, pregnant people then have to shoulder the cost of travel and the abortion, as national governments only fund abortion care for their own residents. Feminist activists help fundraise for pan-European surgical abortion, as well as the distribution of medication abortion to regions where it’s illegal, but second-trimester abortions for non-Dutch residents can cost up to 1,100 euros. Abortion travel also delays care, which increases a pregnant person’s health risks.

Twelve-week bans in the US won’t end the need for abortion care in the second trimester, because there will always be women who lack the knowledge that they’re pregnant before then. But if Republicans wanted to reduce the need for abortion after 12 weeks, they could back straightforward policies to make the procedure more accessible and affordable.

A Texas judge just issued a national ruling against medication abortion. What now?

Originally published in Vox on April 8, 2023.
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A decision in a highly anticipated federal court case was issued Friday night: A district judge in Texas, with longstanding and outspoken anti-abortion views, suspended the US Food and Drug Administration’s approval of mifepristone, a widely used drug to end pregnancies.

But the judge, Matthew Kacsmaryk of the Northern District of Texas, ordered that his decision would not take effect for seven days to allow the federal government time to appeal his decision. Within hours, both the US Justice Department and Danco Laboratories, a manufacturer of mifepristone, announced their plans to challenge the ruling.

For now, access to the drug remains unchanged.

Adding to the chaos and uncertainty, a second and competing federal court decision regarding mifepristone was released Friday in Washington state, in a case led by 17 Democratic attorneys general who argued the FDA had actually been too restrictive when it approved mifepristone.

The federal judge in that case, Thomas Rice, issued a preliminary injunction blocking the FDA from taking “any action to remove mifepristone from the market or otherwise cause the drug to become less available.”

While Rice’s decision applies only to the 17 states involved in the lawsuit, his order would conflict with the nationwide injunction Kacsmaryk just issued, which could set up an accelerated path for the US Supreme Court to take up the issue. The Biden administration said it is still reviewing the Washington state decision.

Kacsmaryk’s decision was riddled with false statements about medication abortion and the risks of mifepristone, which has been used by millions of women since it was first approved by the FDA 23 years ago. It’s unprecedented for a district judge to reverse the FDA’s approval of a drug, and some reproductive rights groups warn this could set the stage for similar challenges to other drugs anti-abortion groups oppose, like birth control and emergency contraception.

On Friday night, President Biden vowed to fight the Texas decision, emphasizing that if it were to stand, “there would be virtually no prescription approved by the FDA safe from this kind of attack.”

Sen. Ron Wyden (D-OR), who chairs the Senate Finance Committee that oversees the FDA, said in a statement that he believes the FDA has the authority to ignore Kacsmaryk’s ruling. “The FDA, doctors, and pharmacies can and must go about their jobs like nothing has changed and keep mifepristone accessible to women across America,” he said.

The availability of the drug will ultimately be decided by higher courts. But if mifepristone were to be pulled off the market, the consequences for access to abortion would be severe. Medication abortion — referring to the combination of mifepristone and misoprostol — accounts for more than half of all abortions in the US, and is used typically within the first 10 to 12 weeks of a pregnancy. It’s become the most common method for ending pregnancies in the United States, partly due to its safety record, its lower cost, diminished access to in-person care, and greater opportunities for privacy.

The anti-abortion movement has been trying to restrict access to medication abortion since before the overturn of Roe, but past attempts to challenge the FDA’s approval process were all summarily rejected. The Texas lawsuit and the plaintiffs’ demand for a nationwide injunction represent the increasing aggressiveness of the anti-abortion movement to take aim at abortion access not only in conservative states controlled by Republicans, but also in deep blue states run by Democrats.

What is mifepristone?

Mifepristone is a prescription drug that works by blocking the hormone progesterone, which maintains the interior of the uterus. If progesterone is blocked, the uterus can’t support a pregnancy and the embryo is detached.

For medication abortions, a second drug — misoprostol — is then used. Misoprostol has been around since the 1970s and was first developed to treat stomach ulcers. An individual seeking to end a pregnancy would take misoprostol 24 to 48 hours after mifepristone, causing their cervix to soften and their uterus to contract and expel the embryo.

Mifepristone is also used for other situations like miscarriage management, and helping patients with Cushing’s syndrome who also have Type 2 diabetes. Lawyers for the plaintiffs insist restricting mifepristone for abortion won’t impact patients who use the drug for other reasons, but already some pharmacists and doctors have resisted prescribing misoprostol to patients, wary of breaking new laws or suspicious patients will use the drugs covertly for an abortion.

The drug was authorized by the FDA in 2000 and is approved for ending a pregnancy in the US up to 10 weeks’ gestation, though the World Health Organization recommends mifepristone up to 12 weeks.

Between 2000 and 2018, more than 3.7 million women in the United States used the medication — sold under the brand Mifeprex — to end an early pregnancy. In 2016, the FDA reported that mifepristone’s “efficacy and safety have become well-established by both research and experience, and serious complications have proven to be extremely rare.” Three years later, the agency approved a generic version, GenBioPro.

Why is there a lawsuit attacking mifepristone?

Back in November, a lawsuit challenging the legality of mifepristone was filed on behalf of a coalition of anti-abortion groups and doctors known as the Alliance for Hippocratic Medicine. Led by the conservative legal advocacy group Alliance Defending Freedom, the lawsuit claims the FDA caved to political pressure under Bill Clinton when it approved mifepristone more than 22 years ago, and it should thus be pulled from the market.

The lawsuit claims the FDA didn’t properly assess mifepristone’s safety, and that the federal government has put people at risk more recently by making the medication easier to obtain. Examples it cites include the FDA extending in 2016 the recommended window of time to take mifepristone from seven weeks of a pregnancy up to 10, and removing a requirement in 2021 that women must pick up mifepristone in person, thereby making telehealth and mail orders more accessible.

The National Academies of Sciences, Engineering, and Medicine has affirmed medication abortion as a safe method to terminate pregnancy, and concluded that there is no medical need for the drugs to be administered in the physical presence of a health care provider. The FDA has also repeatedly rejected the evidence the plaintiffs claim shows medication abortion is unsafe.

The case has virtually no scientific merit, and challenging the use of a drug that has been studied and safely used for over two decades is highly unusual. Jack Resneck Jr., the president of the American Medical Association, said in a statement Friday night that Kacsmaryk’s “disregard for well-established scientific facts in favor of speculative allegations and ideological assertions will cause harm to our patients and undermines the health of the nation.”

Most Americans also believe medication abortion should be accessible. A poll released in early March found majorities of Americans support keeping medication abortion legal and allowing women to use it at home to end an early-stage pregnancy. Another recent survey found 59 percent of voters disapprove of overturning the FDA’s approval of abortion medication, including 72 percent of Democrats, 65 percent of independents, and 40 percent of Republicans.

But legal experts concede these are legally unpredictable times given the politicization of the courts. The federal lawsuit was intentionally filed in Amarillo, Texas, so that Kacsmaryk, a conservative judge, would hear the case. Kacsmaryk was appointed by Donald Trump and is a former Christian activist who has openly opposed abortion for decades.

Last year, he ruled that federal law prohibiting certain forms of discrimination by health providers does not protect against anti-LGBTQ discrimination, and in a separate case, he concluded that teenagers can’t access birth control without their parents’ permission under Title X, a federal program that provides family planning and preventative health services.

What are the implications of the decisions?

Both decisions in Texas and Washington state were issued by lower courts, so these legal battles are not over. The federal government has already said it will appeal the Texas decision, but it’s unclear if the Biden administration will appeal to the Fifth Circuit, or go directly to the US Supreme Court.

Will mifepristone remain available? One possibility is that the Fifth Circuit or the Supreme Court issues a “stay” as the case continues to be litigated, meaning the drug could continue to be prescribed, while the lawsuit stretches on. When Roe was on the books, there were lots of court-ordered abortion bans upheld in district courts like Kacsmaryk’s, but then never enforced because lawyers would successfully win “stays” as they proceeded to challenge the bans in higher-level courts. Whether appellate courts in the post-Roe era would be as willing to block a lower judge’s order while the case continues is an open question.

David Cohen, a law professor at Drexel University who specializes in reproductive rights law, said before Kacsmaryk issued his order that typically an appellate court would consider whether a district court order would be so disruptive to the status quo that it needs to be halted while they consider the case. In normal times, abruptly taking off the market an FDA-approved drug that has been safely used by millions of women for over 20 years would certainly meet the threshold of “very disruptive” to the status quo.

“But I think we are in a world where the conservative Fifth Circuit feels very emboldened, so we can’t count on” a stay, Cohen told Vox. It’s possible, especially given the Washington state decision, that the Biden administration skips the Fifth Circuit and appeals directly to the Supreme Court. “We’ve seen more litigants doing that in recent years, though usually it’s been conservative litigants,” Cohen explained. “I don’t know if the FDA would want to do that, but it’s possible they think they’d get a fairer shake at the Supreme Court.”

What options for abortion are still available right now?

For at least the next week, nothing will change,

If mifepristone is ultimately pulled from the market, people seeking abortions could still access care at in-person clinics for surgical abortions. But those procedures typically cost more money, and require more time and resources from already-strapped abortion clinics. In its legal filing opposing the Texas case, the Justice Department warned that taking mifepristone off the market would lead to delays and overcrowding at these clinics, which were already managing an influx of out-of-state patients since Roe’s overturn.

Another option that would remain even if the order takes effect is ordering pills either from the European-based nonprofit Aid Access, which bypasses US restrictions by prescribing the drugs to patients from overseas, or through alternative methods vetted by the reproductive justice group Plan C such as mail forwarding. “We will not let this unjust ruling stop people from accessing abortion pills, which are readily available through alternate supply routes in the US,” Plan C co-director Elisa Wells said Friday night.

Another option would be pursuing medication abortion using only misoprostol. While not FDA-approved, this method is backed by the World Health Organization, and a common way of ending pregnancies around the world. In February, researchers found misoprostol-only abortions in the US to be 88 percent effective, with few incidents of serious adverse events or signs of a potential abortion complication. In comparison, research in the US on using mifepristone and misoprostol together has shown success rates of 95 percent. But research on misoprostol-only abortions in other countries has also shown similar efficacious results, ranging between 95 and 99 percent.

Abortion providers, though they expressed adamant opposition to the Texas lawsuit, have been preparing to offer misoprostol-only abortions if mifepristone is taken off market. The National Abortion Federation, in its clinical guidelines, says that “where mifepristone is either not legally available or inaccessible, misoprostol-alone regimens may be offered.” Because misoprostol has been FDA-approved to treat stomach ulcers and can be prescribed off-label for solo use, there is less concern that access to that drug will disappear.

There are also pending federal lawsuits to expand access to medication abortion

In addition to battling this lawsuit from anti-abortion groups, reproductive health organizations have been planning their own legal strategies to expand access to abortion pills. In January, two such lawsuits were filed, claiming two states’ restrictions on mifepristone illegally preempt the FDA.

Through the passage of the Federal Food, Drug, and Cosmetic Act in 1938, Congress empowered the FDA as the sole agency to approve drugs in the US. It’s responsible for reviewing a drug’s safety, weighing its risks and benefits, and regulating appropriate conditions for safe and effective use.

With this in mind, GenBioPro, the generic manufacturer of mifepristone, argued in a lawsuit that West Virginia’s state abortion ban is unconstitutional because it violates the supremacy and commerce clauses of the US Constitution, which empowers the FDA as the sole regulator of drugs across the country.

In response to Kacsmaryk’s ruling, GenBioPro issued a statement affirming that as it reviews the Texas decision, it will continue to make its product available. “The bottom line is, we are confident in the legality of mifepristone’s approval,” CEO Evan Masingill said.

A similar case, filed in January by an OB-GYN in North Carolina, challenged state officials for imposing restrictions on mifepristone that go beyond what the FDA requires. North Carolina requires doctors to provide mifepristone in person at a particular type of facility after a 72-hour waiting period and, in some cases, an ultrasound.

Experts say there is a “strong, though legally uncertain” argument that the supremacy clause of the Constitution gives the federal government authority over these conflicting state rules. This idea — that federal regulation of drugs would take precedence, and a state cannot ban a drug that has been given federal approval — is known as the preemption argument.

For now, legal scholars say it’s unclear how preemption arguments will play out in court. Courts often grant deference to the FDA, though there are relatively few examples involving drugs. The main precedent is a 2014 case where a federal judge struck down a Massachusetts effort to restrict the opioid Zohydro, since the FDA had approved the painkiller. If the plaintiffs win their case, millions more people could have easier access to mifepristone.

The anti-abortion movement’s next radical legal argument

Originally published in Vox on March 20, 2023.
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Until very recently, nearly everyone accepted some basic ideas about the American legal system. If a state passes a law, and that law is challenged in court, we should act as if that law is still in effect while the case works its way through the court system.

That changes only if a judge issues a “preliminary injunction” blocking the law while the lawsuit plays out or a “permanent injunction” to strike the law down. In that case, we all act as if the law is not in effect.

But in recent years, an aggressive wing of the anti-abortion movement has been working to challenge this broadly held idea of legality — a push that has attracted little notice, but is further complicating the debate over abortion access. Jonathan Mitchell — the architect behind Texas’s notorious SB 8 law that bans abortions after about six weeks of pregnancy, who is currently suing three women for allegedly helping a friend end a pregnancy — has been advancing the idea that abortion providers could still be held liable for pregnancies they help terminate under restrictive state laws, even if the law is blocked by the courts when the abortion occurs.

Prior to Dobbs v. Jackson, abortion rights lawyers beat back a host of abortion restrictions by arguing they were unconstitutional, violating the protections afforded by the Supreme Court’s 1973 decision. The end of Roe v. Wade has stripped Americans of a fundamental backstop to attacks on abortion access, meaning legal challenges to both state and federal abortion laws are being fought now in new waters.

The recent controversy surrounding Walgreens’ announcement to 21 Republican state attorneys general that it would not dispense medication abortion to their residents has centered primarily on four states that have abortion restrictions that are either blocked in court or pending in the legislature. A law the Montana legislature passed in 2021 barring telemedicine for abortion, for example, is currently enjoined. Walgreens consumers, Democratic politicians, and most journalists have said that as a result in those four states, at least for now, it’s legal for Walgreens to dispense the pills.

But this new push to hold providers liable for breaking laws that are enjoined by courts is making decisions from health care providers, including pharmacy chains, more complicated. Legal experts interviewed by Vox agreed it’s simply unclear right now how courts would rule on whether you can be successfully prosecuted for breaking a law under injunction, and the Supreme Court has disagreed on the question in the past.

The uncertain legal landscape notwithstanding, abortion rights advocates want companies to resist threats from Republicans and anti-abortion activists. “Through misinformation and intimidation, anti-abortion advocates are working to create an atmosphere of fear and confusion that goes against decades of scientific evidence with the goal of pushing abortion care further out of reach for many people, especially those from marginalized groups,” Elizabeth Nash, a state policy expert at the Guttmacher Institute, told Vox.

But for years, abortion rights groups have correctly argued that the public has underestimated the warnings and intentions of the anti-abortion movement. So to ask companies and individuals now to presume anti-abortion lawyers are bluffing about their novel, and even ridiculous, legal threats, or to assume conservative judges would not side with those lawyers as they have often in the past, requires a stretch of the imagination.

How the anti-abortion movement wants to weaken the protection of a court injunction

In 2018, anti-abortion lawyer Jonathan Mitchell penned a law review article arguing that if a court issues an injunction, it should be understood that those laws are still in effect, and anyone who violates those laws is not shielded from future prosecution.

“If a court were to dissolve the injunction, the executive would be free to enforce the statute again — both against those who will violate it in the future and against those who have violated it in the past,” Mitchell wrote.

That context has been largely missing from coverage of the abortion-pill wars. In the days following news about Walgreens, advocates for reproductive rights strongly suggested the pharmacy was needlessly capitulating to Republican political pressure. “California will not stand by as corporations cave to extremists and cut off critical access to reproductive care and freedom,” California Gov. Gavin Newsom had said. Writing for CNN, legal historian Mary Ziegler said Walgreens’ announcement shows “the mere threat of legal consequences counts for more with some in corporate America than the very real lives of the women.”

But the growing legal debate over injunctions adds more layers to Walgreens’s apparent corporate cowardice.

Mitchell’s argument about injunctions was mostly ignored until 2021, when Texas passed SB 8, a bill that allows private citizens to enforce the state’s six-week abortion ban through civil litigation and receive a cash bounty if they’re successful. The SB 8 law also includes a provision that says an individual cannot cite as a defense any court decision that was later overruled on appeal or by a subsequent court. Drexel law professor David Cohen called this SB 8’s “sword of Damocles” provision — hanging over the heads of abortion providers even in the event a court provides relief from an anti-abortion law.

Rachel Rebouché, a law professor at Temple University, said while it seems “common sense” that someone would not be retroactively liable for actions they took while a law was enjoined — as it would present due process concerns — the law is not “crystal clear, and the anti-abortion movement is really seizing on that.”

In 1982, in a US Supreme Court case, the justices disagreed over the liability protection afforded by injunctions. Two justices, Thurgood Marshall and William Brennan, argued an injunction offers “permanent protection from penalties for violations of the statute that occurred during the period the injunction was in effect.” But Justice John Paul Stevens, in his concurring opinion, questioned whether federal courts could really offer that. In 2004, law professor Vikram David Amar described the implications of Justice Stevens’ position as “quite scary.”

There are some hints that the current Supreme Court would not be receptive to radically changing the status quo on injunctions. In 2020, the Court decided a voting rights case where it vacated an injunction making it easier to vote in South Carolina, but also held that voters who cast their ballots while the injunction was in place would still have those votes counted. And in his concurring Dobbs v. Jackson opinion, Brett Kavanaugh wrote that he did not believe a state could “retroactively impose liability or punishment for an abortion that occurred before today’s decision.” Still, these are not firm assurances. “I have no doubt [Kavanaugh] would happily change his position in a fully briefed case on this issue if it suited him,” Cohen, of Drexel’s law school, said.

One reason the issue has remained unsettled for so long, University of Virginia law professor Doug Laycock told Vox, is that prosecutors typically just move on if a court vacates an injunction. “They say, ‘we won our point in court, we can enforce the law going forward, and that’s what we really care about.’”

The problem now, Laycock explains, is that feelings on abortion are so intense that prosecutors might indeed go after people following the overturn of an injunction, even though in the past they haven’t considered doing so. “We’re seeing doctors who will not rely on the exceptions in these new anti-abortion statutes because they think the pro-life prosecutors are crazy, and who knows what they might charge,” he said. “I think the same thing is going on with respect to pharmacies.”

Cohen, of Drexel, wrote in 2021 about how SB 8 puts lawyers who represent Texas abortion providers in a difficult position. “If you won an injunction, would you advise your clients to start performing abortions with the risk of substantial liability hanging over their head if the injunction is reversed any time in the next six years? That would be a hard enough question without the explicit language in SB 8. But with the clause highlighted here, it would likely be very risky.”

Caught in the middle of this legal and political tug-of-war are providers, who are left to play chicken with aggressive anti-abortion lawyers looking to test the limits of what we think of as “legal.”

Rebouché, of Temple’s law school, noted that when Mitchell first published his 2018 law review article, “people thought it was a little crazy.” But then SB 8 happened, and the Supreme Court let it stand. “This is just another example of the anti-abortion movement throwing everything at the wall and seeing what sticks.”

The sole US supplier of a major abortion pill said it would not distribute the drug in 31 states

Originally published in Vox.com on March 17, 2023.
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Earlier this month, Politico broke news that Walgreens, the nation’s second-largest pharmacy chain, assured 21 Republican attorneys general that it would not dispense abortion pills in their states should the company be approved to dispense them. The decision was met with sharp protest by Walgreens customers, abortion rights activists, and Democrats, who accused the pharmacy of caving needlessly to pressure.

But fear of state prosecution is not the only factor shaping Walgreens’ decision-making. Another previously unreported constraint on the company is that its sole supplier of Mifeprex — the brand-name drug for the abortion pill mifepristone first approved by the Food and Drug Administration in 2000 — circulated a list to its corporate clients in January naming 31 states that it would not supply the abortion medication to. Vox spoke with two sources who had reviewed that list recently.

The sole US distributor for Mifeprex is AmerisourceBergen, one of the largest pharmaceutical distribution companies in the world. (The federal government is currently suing AmerisourceBergen for allegedly distributing opioids while knowing they would later end up on the illegal market. The Pennsylvania-based company has denied this.) Back in January, AmerisourceBergen created its list of 31 states using as a source the website of the Guttmacher Institute, a reproductive research organization that tracks state abortion restrictions, according to sources with knowledge of the list’s origin.

The list’s existence underscores the precarious state of abortion rights in the US in the wake of Dobbs v. Jackson — the 2022 Supreme Court ruling that struck down Roe v. Wade, effectively leaving abortion rights to each state. Walgreens drew condemnation for saying it would not dispense abortion pills, even in states where it’s currently legal to do so. AmerisourceBergen’s list indicates another reason influencing Walgreens’ stance: a distributor — it’s the only one for this drug — had signaled that it would not supply pharmacies with abortion pills.

Walgreens and Danco Laboratories, the manufacturer of Mifeprex, declined to comment. A source with knowledge of the contractual agreement between Walgreens and AmerisourceBergen told Vox that the parties are legally barred from talking publicly about the supplier, but that advocates have been trying to persuade AmerisourceBergen to adopt a less risk-averse stance on abortion-pill distribution.

Lauren Esposito, a spokesperson for AmerisourceBergen, told Vox over email that the situation “is dynamic and ever evolving. Any information that you’re referring to from January is certainly out of date by now. Additionally, as I’m sure you can appreciate, for contractual purposes we are not able to discuss specific products.” The company later released an additional statement, emphasizing that AmerisourceBergen does not “independently decide what medications should be available to health care professionals as part of their treatment plans” and does “not make clinical decisions or values-based judgements on which FDA approved products it distributes.”

Vox asked Guttmacher about the supplier’s list and its reported use of the institute’s site as a guide for compiling the list. “We would like to understand what data AmerisourceBergen is basing these claims on, as we are not aware of any policies that would prevent the shipping of mifepristone to such a large number of states,” said Elizabeth Nash, a Guttmacher policy analyst. “Private companies should be extremely careful not to limit access to mifepristone in response to threats from anti-abortion groups or politicians.”

Abortion rights advocates and consumers responded with outrage to the Politico report, calling for a boycott of Walgreens until it reverses its stance. At particular issue is the fact that four states on Walgreens’ list — Montana, Kansas, Iowa, and Alaska — have restrictions on pharmacists that are blocked in court. California Democratic Gov. Gavin Newsom announced he would not renew a multimillion-dollar contract with the pharmacy chain to signal his disapproval.

Walgreens spokesperson Fraser Engerman maintained the company’s position hasn’t changed, and that they still intend to dispense mifepristone “in any jurisdiction where it is legally permissible to do so.”

In January, the Food and Drug Administration announced that brick-and-mortar pharmacies could apply for certification to sell abortion medication at their stores, a move hailed as an important step toward expanding access to the safe and effective drug that has become the most common method for ending pregnancies in the United States.

Representatives from CVS and Rite Aid, which like Walgreens said they would seek certification, have remained conspicuously quiet on the issue for the last two weeks, and did not return requests for comment. (No drugstore has yet been certified, and it is not clear how long the process will take.)

The ongoing debate over what pharmacies like Walgreens can and should do when it comes to dispensing mifepristone reflects the political challenge of navigating the patchwork of conflicting state abortion restrictions in the post-Roe era. With a bevy of new laws and litigation, individuals, abortion providers, and companies are left to make consequential decisions in a highly fraught and confusing legal environment — which, in the case of Walgreens and AmerisourceBergen, means inaction in the face of uncertainty.

Pharmacists are caught in the middle

Caught in the middle of this legal and political tug-of-war are abortion providers. While it’s easy for Democratic governors in states like Illinois and California to tell companies they should dispense medication abortion, it’s harder to insist that they should put their pharmacists at risk.

“Violating the has-to-be-done-by-a-physician requirements in some of these states is punishable by jail,” a Walgreens spokesperson told the New York Times. “In other states, it’s punishable by a civil fine, and in a number of them it’s punishable by licensing sanctions. And so these are restrictions that present real risks to pharmacists.”

The 21 states where Walgreens has said it will not dispense mifepristone fall into a few different categories, explained Nash of Guttmacher. Some have banned abortion entirely, while others have laws requiring physicians to dispense drugs in-person, or require in-person counseling and ultrasounds, making the prospect of dispensing mifepristone through a pharmacy impractical. And still others, like Alaska, should feasibly be able to dispense through a pharmacy, Nash said.

“Overall there’s a lot of confusion in the marketplace as pharmacies and pharmacists try and follow all the laws and regulation and litigation,” said Ilisa Bernstein, the interim CEO of the American Pharmacists Association. “It’s unsettled right now.”

Bernstein told Vox that beyond legal risks, members are grappling with new safety issues: “Pharmacy team staff safety is a concern, whether it’s getting into the pharmacy and going through people who may be demonstrating and picketing outside or in the pharmacy, where team members want to be sure they’re in a safe space when they’re working,” she said. Recently anti-abortion activists protested Walgreens’ annual shareholder meeting, casting drugstores as the new abortion clinic.

Next week the American Pharmacists Association is holding its annual meeting where hundreds of delegates from across the country plan to revisit the group’s policies on mifepristone and reproductive health care.

Regardless of what pharmacists want their group’s policies to be, they will remain bounded by the FDA’s Risk Evaluation and Mitigation Strategies (REMS) list, a restrictive designation the federal government places on mifepristone over the objections of groups like the American Congress of Obstetricians and Gynecologists. Pharmacists will also be circumscribed by the lawyers of their companies, and other actors involved in the medication abortion supply chain, like drug distributors and lawmakers.

Esposito, the spokesperson for AmerisourceBergen, told Vox, “We continue to make FDA-approved medications, including reproductive health medications, available to health care facilities and providers in all 50 states and territories that meet local, state, and federal requirements to distribute and dispense.”

But whether AmerisourceBergen will let Walgreens and other drugstores sell Mifeprex in all the locations pharmacies would be willing to dispense them from is another question.

How abortion rights advocates won every ballot measure this year

Originally published in Vox on November 11, 2022.
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Americans voiced their preference for abortion rights on Tuesday, casting votes in support of reproductive freedom everywhere they appeared on the ballot: Kentucky, Michigan, Vermont, Montana, and California.

Counting a pivotal ballot measure Kansas voters weighed in on in August, reproductive rights have been on the ballot in six states since the Supreme Court overturned Roe v. Wade in June. Each time, abortion rights supporters have won.

While Democratic candidates running on abortion access also did extremely well in their contests this week, the vote tallies indicate that the ballot initiatives were often able to draw even more support than the Democratic candidates, garnering votes from individuals who otherwise cast ballots for Republicans, libertarians, or no candidate at all.

“Organizers communicated in a nonpartisan way and that was key,” said Ashley All, who served as communications director for the pro-choice coalition in Kansas. “Their messaging around personal liberty and reproductive freedom and protecting the constitutional rights of women to make the decisions for themselves resonated because it’s shared American values.”

The organizers also succeeded in winning over voters who may personally oppose abortion or have reservations about it. While a majority of Americans say they believe Roe v. Wade should be upheld, roughly one-third of those backing legal abortion do not personally support it. And many who support abortion rights believe it should only be legal in cases of rape or a threat to a woman’s life.

Ethan Winter, the research and strategy director for Families United for Freedom, an abortion rights political action committee, emphasized that the ballot measure campaigns all leaned heavily on persuasion tactics.

“Montana is a heavily Republican state, Kentucky is a heavily Republican state,” he told Vox. “All of these victories depend on Republicans voting for you, on people who self-identify as ‘pro-life’ voting for you.” In Kansas, where Trump won handily in 2020 and registered Republicans outnumber Democrats almost two to one, the pro-choice side won by a nearly 20-point margin. Even California’s measure codifying abortion rights in the state constitution passed this week with roughly 6 percent more support than other Democrats currently have on the statewide ballot.

Abortion rights organizers say they hope their successes this year across diverse states inspires other leaders to follow suit. How to get issues on the ballot varies from state to state; in some cases citizens can collect signatures, while in others lawmakers have to approve turning issues over to voters. In Michigan, activists collected more than 750,000 signatures to get their abortion rights measure on the November ballot. In Montana, Kentucky, and Kansas, by contrast, Republican lawmakers had voted to place their anti-abortion measures on the ballot.

“Our resounding victory now provides a model for the future of coalition-based reproductive ballot initiatives all across the country,” declared Nicole Wells Stallworth, the executive director for Planned Parenthood Advocates of Michigan, in a press conference on Wednesday.

“I’m hoping other states are looking at the outcomes of last night,” Jodi Hicks, the head of Planned Parenthood Affiliates of California, told Vox. “And looking at what they too can do and really start polling, message-testing, and laying the groundwork.”

Voters don’t like big status quo disruptions, and overturning Roe was just that

This past summer when Kansas voters went to cast their ballots, advocates for abortion rights were cautiously optimistic they’d have one advantage on their side: status quo bias.

Americans tend not to like big, disruptive changes, which is why political science researchers believe they observe a “status quo bias” when people weigh in on ballot initiatives. Voters often reject measures they perceive as introducing major change.

Anti-abortion politicians in Kansas had proposed an amendment to the Kansas constitution that would have overruled a Kansas Supreme Court decision affirming Kansans’ right to end a pregnancy. Passing the amendment would have given state lawmakers the power to ignore this ruling and legislate a total abortion ban in the wake of the Dobbs decision.

Activists in Kansas, in other words, could frame the amendment as an effort to take away rights Kansans currently enjoyed under their state constitution, something they called extremist, radical, and disruptive. This general electoral instinct to avoid major shifts to the status quo, organizers believe, helped them defeat the amendment in August.

While the abortion ballot choices on Tuesday weren’t quite as straightforward as asking voters whether they want to remove an existing state constitutional protection, organizers did lean on “status quo bias” messaging in their respective campaigns. In Michigan, for example, though Proposition 3 was an affirmative amendment to codify reproductive freedom in Michigan’s constitution, activists framed their language around the idea of restoring the rights of Roe v. Wade, of bringing back the reality Americans had known for five decades.

In Kentucky activists similarly emphasized a theme of restoration. “We focused our messaging on restoring access and making sure things do not go any further in the extremist direction,” explained Rachel Sweet, who led the Kentucky coalition organizing to defeat the anti-abortion amendment.

Abortion rights organizers used state-specific messaging to win

Activists and researchers experimented with different messages and messengers to win their ballot initiative campaigns, deploying themes that were specific to the histories and values of each state.

In Montana, for example, organizers looked to capture the deep sense of pride voters have in their state’s right to privacy. “Montanans of every ideology here are deeply proud of our constitution which enshrines the right to privacy,” said Hillary-Anne Crosby, a spokesperson for the coalition organizing to defeat Montana’s anti-abortion ballot measure. “This amendment really came down to private medical decisions.”

Montana’s referendum — known as LR 131 — was spurred by a bill Republican lawmakers passed last year asking voters to affirm that an embryo or fetus is a legal person with the right to medical care if it survives an abortion or delivery. Under the law, health care providers could face up to 20 years in prison and a $50,000 fine if they failed to provide such care.

While Republican lawmakers framed the measure as a moral choice for anyone opposed to abortion, reproductive rights advocates argued that the proposal itself had little to do with abortion and everything to do with palliative care and compassion for bereft parents.

That’s because infanticide is already illegal in Montana, and the idea that infants were being killed after an abortion is intentionally misleading, part of a longstanding effort by anti-abortion leaders to depict “botched abortions” that they say can result in live births.

Under current Montana law, if an infant has a fatal prognosis parents can spend those final and few moments holding their dying child and saying goodbye. Under LR 131, a doctor would have been obligated to take the infant away to attempt medical treatment, even if they knew nothing would work.

In mobilizing support against the referendum, advocates chose to de-emphasize abortion, often not mentioning the word at all. They ran ads featuring neonatologists, obstetricians and pediatricians, and grieving parents who said elected officials wanted to politicize their tragedies. Leaning in on status quo bias, doctors gave media interviews explaining how the proposed amendment would threaten the existing rights of parents and criminalize “the current practice of medicine.”

“We’re not trying to pull the wool over anyone’s eyes, we’ve been clear that one of the values of Compassion for Montana Families is uplifting and empowering reproductive and sexual health care,” Crosby told Vox. “But we felt abortion language was a misleading, deceptive thing to be talking about, and we wanted to accurately reflect what the bill in question would mean.”

This doesn’t mean Montana advocates aren’t celebrating the outcome as a victory for reproductive rights. “Conservatives tried to make abortion a boogeyman and people didn’t buy it,” Crosby added.

Vermont organizers also emphasized, in their campaign messaging, doing things “the Vermont way” — referring to the state’s independent and nonpartisan ethos.

“Vermont is sometimes seen as this very liberal place because of Bernie Sanders or whatever, but historically Vermont has held a Republican majority as well as the governor’s seat, and Vermonters regularly split their tickets,” said Lucy Leriche, a spokesperson for the abortion rights coalition in Vermont.

Vermont, unlike most other states, also enjoyed 50 years of unlimited and unrestricted reproductive freedom. While states were permitted under Roe v. Wade to restrict pregnancies after viability (typically around 24 weeks in a pregnancy) Vermont lawmakers never did.

“The [anti-abortion] side is very quick to talk about all the bad things that would happen if you don’t restrict abortion rights, but in Vermont we never had any restrictions, so those arguments really do fall flat,” Leriche told Vox. “They don’t stick because we know better.” The measure to codify reproductive rights in Vermont’s constitution passed on Tuesday with 77 percent of the vote.

Abortion rights activists haven’t historically focused on state ballot measures

Shoring up abortion rights on the state level was not something reproductive health advocates prioritized when Roe v. Wade provided a nationwide constitutional protection. Anti-abortion activists would occasionally push state ballot measures, often in deep red states, but fighting them at the polls seemed less critical than challenging them in court for violating Roe.

“Ballot measures are a space where there hasn’t been a ton of money on the pro-choice side and I think Families United for Freedom is indicative of more money moving in, and what I hope to be a larger trend,” said Winter. Families United for Freedom raised about $2 million this cycle, contributing $600,000 in Kansas, $275,000 in Kentucky, $500,000 in Michigan and $275,000 in Montana. Rachael Bedard, the PAC’s executive director, told Vox that they partnered with and supported local grassroots organizations, providing them with polling and media support, and avoided “a super-imposed national strategy.”

Sweet, who managed the campaigns in both Kentucky and Kansas, told Vox that their success was driven by the expertise of these local grassroots leaders. “We also had a lot of volunteers who have never knocked doors for a candidate, and they don’t consider themselves super politically active,” Sweet said. “But they are concerned and motivated by this one issue.”

One key research point Families United for Freedom found is that even among voters who supported the overturn of Roe v. Wade, a majority of them want abortion to be legal to save the life of the mother and in the case of rape and incest. Even in a hypothetical scenario in which abortion was illegal, the group found, 16 percent of those who said they approve of the Dobbs decision wouldn’t want the woman who had an abortion to face penalties.

“In other words,” Bedard said, “they disapprove of abortion but less than they disapprove of criminalization.” Winning on these abortion ballot measures, Bedard said, means creating the space for someone to continue living their life as a “pro-life” person, while emphasizing that doesn’t extend to making their neighbor’s choice for them.

“We need to let voters have their own personal feelings about abortion, but invite them to join us in the fundamental belief that women should make the decisions for themselves,” added Ashley All, who joined Families United for Freedom after defeating the Kansas ballot measure. “That is pro-choice and that is a way to really bridge the gap.”

What a lawsuit in Mississippi tells us about the future of abortion pills

Originally published in Vox on June 29, 2022.
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As some states have moved to fully ban abortion in the wake of Dobbs v. Jackson Women’s Health, new questions emerged about abortion pills: Do states have the legal authority to outright ban drugs that have been approved by the U.S. Food and Drug Administration?

An ongoing federal lawsuit in Mississippi could provide a glimpse at the answer. GenBioPro, the manufacturer of generic abortion pills, is fighting to overturn state restrictions that impede access to the abortion pill mifepristone. Their lawsuit, filed in 2020, hinges on an argument that many legal experts expect other states and advocates to make in the coming months: that Mississippi’s restrictions on medication abortion are unduly excessive, illegally pre-empting the FDA’s authority on drug safety.

The FDA approved mifepristone for use in 2000. Over the next 18 years, more than 3.7 million women in the United States used the medication — sold under the brand Mifeprex — to end an early pregnancy. In 2016 the FDA reported mifepristone’s “efficacy and safety have become well-established by both research and experience, and serious complications have proven to be extremely rare.” Three years later the agency approved GenBioPro’s generic version.

Today medication abortion — a combination of both mifepristone and misoprostol — account for more than half of all abortions in the US, and fights over accessing the pills are expected to be among the most fiercely contested in the post-Roe era.

Just hours after the US Supreme Court overturned Roe, President Joe Biden gave a speech promising to protect a woman’s access to drugs approved by the FDA, including mifepristone. Biden announced he was directing the federal Department of Health and Human Services “to ensure that these critical medications are available to the fullest extent possible” and Attorney General Merrick Garland pledged to use the powers of the Justice Department to crack down on states trying to ban medication abortion.

But the Biden administration has stayed quiet on the Mississippi lawsuit. The White House declined to comment on the case, as did the FDA and DOJ. HHS did not return requests for comment.

Mississippi has urged for a dismissal of the case. Judge Henry Wingate, a Reagan appointee on the United States District Court for the Southern District of Mississippi, requested that both parties provide written submission on the impact, if any, of the Dobbs decision on the lawsuit, and on Mississippi’s “trigger law” banning abortions, which is set to take effect next week. Submissions are due on Thursday.

A ruling in favor of Mississippi could have implications for other jurisdictions seeking to ban abortion pills in a post-Roe landscape.

If upheld, it “would also open the floodgates for states to substitute their judgment for FDA’s in other controversial areas of medicine — some of which we may be aware of — some of which we may not be,” said Delia Deschaine, a DC-based attorney who specializes in FDA regulation. “For example, if there were a group of individuals opposed to palliative care, a state could conceivably limit access to medications that are approved for use in that context. This then becomes a situation where the practice of medicine using pharmaceuticals unpredictably varies between states — which creates its own host of public health issues.”

What it means to “pre-empt” the FDA

Through the passage of the Federal Food, Drug, and Cosmetic Act in 1938, Congress empowered the FDA as the sole agency to approve drugs in the US. It’s responsible for reviewing a drug’s safety, weighing its risks and benefits, and regulating appropriate conditions for safe and effective use.

Even though many reproductive health experts — including the American College of Obstetricians and Gynecologists — actually say the FDA has too many restrictions on mifepristone (for example, only certified pharmacies or providers can dispense the drug) everyone must abide by the agency’s determinations.

But many red states, including Mississippi, have passed laws that go even further than FDA’s rules around mifepristone. For example, Mississippi requires a doctor to physically examine a patient prior to offering the drug, and for patients to ingest the medication “in the same room and in the physical presence of” the physician who gave it to them, rather than taking the medication at home.

Experts say there is a “strong, though legally uncertain” argument that the Supremacy Clause of the US Constitution gives the federal government authority over these conflicting state rules. Indeed, GenBioPro has argued Mississippi’s law is “an impermissible effort by Mississippi to establish its own drug approval policy and directly regulate the availability of drugs within the state.”

This idea — that federal regulation of drugs would take precedence, and a state cannot ban a drug that has been given federal approval — is known as the preemption argument.

For now, legal scholars say it’s unclear how preemption arguments will play out in court. Courts often grant deference to the FDA, though there are relatively few examples involving drugs. The main precedent is a 2014 case where a federal judge struck down a Massachusetts effort to restrict the opioid Zohydro, since the FDA had approved the painkiller.

“The fact that this case relates to a medication that is used in abortion is one reason we might see the district court take a different stance than other courts on this issue,” said Deschaine.

Anti-abortion advocates maintain that states have the authority to restrict or ban mifepristone, because states can regulate medical practice, and the FDA lacks the authority to regulate abortion. Legal scholars also note that Congress has never explicitly said that FDA drug approval supersedes state law, though it has expressed that for medical devices.

While the DOJ declined to comment on the GenBioPro case, Attorney General Garland’s recent public statements suggest the agency is thinking about the preemption argument. “The FDA has approved the use of the medication Mifepristone,” Garland said Friday, adding that, “states may not ban Mifepristone based on disagreement with the FDA’s expert judgment about its safety and efficacy.”

What’s next for the GenBioPro lawsuit

Gwyn Williams, an attorney representing GenBioPro, told Vox that in response to the judge’s request, their team submitted a statement reiterating their previous position that the legal issues decided by the US Supreme Court in Dobbs “do not affect GenBioPro’s claims, which are based on federal preemption and not on constitutional rights to privacy or abortion.” Williams says they expect the judge to issue his decision on dismissing the case soon.

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Paul Barnes, a Mississippi Assistant Attorney General representing the state, declined to comment.

Greer Donley, a University of Pittsburgh law professor who specializes in reproductive law, told Vox that one reason why the court has been “pretty delayed” in issuing any rulings could be because the judge “might be trying to look for an opportunity to kick the case.”

If Mississippi fully bans abortion statewide — which it’s set to do next week, though that trigger law is now being challenged in court — then the state’s mifepristone restrictions might become moot. “If there’s a statewide ban, then I can imagine the defendant saying the lawsuit is moot now because all these laws that regulate abortion providers are subsumed by the bigger abortion ban generally,” said Donley.

But Donley says the preemption argument would still have broad merit, since the FDA still acts as a gatekeeper.

“To earn the right to sell a drug product, manufacturers must produce years, if not decades, of expensive, high-quality research proving that the drug is safe and effective,” she wrote, along with law professors David Cohen and Rachel Rebouché in a legal article cited in the Dobbs dissent. “If they are successful, they can sell their product in every state; if unsuccessful, they cannot sell their product anywhere. If a state were to ban abortion, it would in effect ban the sale of an FDA-approved drug.”

In other words, if it is impossible to comply with both state and federal law at the same time, there remains a plausible preemption argument.

Deschaine, the attorney who specializes in FDA regulation, thinks upholding state restrictions on abortion pills could certainly affect whether other drug companies seek to go through the FDA approval process in the future.

“The incentives for developing FDA-approved drug products are strong, but those start to erode the more fractured the regulatory scheme for these products becomes,” she said. “If a company does not believe that it will be able to market its product in all US states/jurisdictions, then it may not be willing to assume the risk of pursuing the drug approval pathway. Indeed, even absent those restrictions, that pathway is very costly and uncertain.”

The coming legal battles of post-Roe America

Originally published in Vox on June 27, 2022.
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When the Supreme Court issued its 6-3 decision in Dobbs v. Jackson Women’s Health, declaring that there is no longer a constitutional right to end a pregnancy, it ushered in a series of new and fiercely contested legal questions about who can be punished for doing so, and where, under newly restrictive state laws.

Can a state punish a resident for getting an out-of-state abortion? Can it punish the provider in another state who facilitated it? Or as Justices Stephen Breyer, Sonia Sotomayor, and Elena Kagan wrote in their dissent: “Can a State prohibit advertising out-of-state abortions or helping women get to out-of-state providers? Can a State interfere with the mailing of drugs used for medication abortions?”

Many anti-abortion activists and conservative legal scholars have long insisted that overturning the 1973 Roe v. Wade decision would lead to a simpler legal landscape — freeing the Supreme Court from the “abortion-umpiring business,” former Justice Antonin Scalia​​ wrote in 1992, and allowing the matters to be decided “state by state.”

But while conservatives fantasized about the supposedly tidier legal landscape of a post-Roe America, other legal scholars warned overturning Roe could make the legal complexities of the last five decades seem quaint.

In his concurring Dobbs opinion, Justice Brett Kavanaugh dismissed concerns that overturning Roe will raise new vexing legal questions. “As I see it, some of the other abortion-related legal questions raised by today’s decision are not especially difficult as a constitutional matter,” Kavanaugh wrote. His arguments: The right to travel between states, as people seeking abortion in states with bans will now need to do, is constitutionally protected. Legal precedent would also prevent states from holding anyone liable for abortions that occurred before Friday’s decision.

With the rise of the internet, telehealth appointments, mail-order pharmacies, and drugs like mifepristone and misoprostol that people can acquire in advance of being pregnant, the questions around what it means to both provide and obtain an abortion have evolved considerably since the pre-Roe days, as have questions about what it means to “cross state lines” to get one. The liabilities involved in all these scenarios are likely to be tested in the years to come.

Ultimately, the end goal for the anti-abortion movement is not a patchwork of abortion-friendly and abortion-restricting states. It’s a country where abortion is illegal and inaccessible and ideally where fetuses are viewed as people, entitled to the same protections as any other individual under the Fourteenth Amendment.

“Until that argument is accepted, the antiabortion movement will use state powers to stop as many abortions as possible, including outside state borders,” wrote three Pennsylvania law professors, Greer Donley of University of Pittsburgh, David Cohen of Drexel University, and Rachel Rebouché of Temple University, in a working paper posted online in February that laid out the legal dilemmas, and was cited directly in the Dobbs dissent. This doesn’t necessarily mean that those attempts will succeed, but it underscores just how uncertain the legal landscape now is.

Though someone is unlikely to be physically barred from crossing a state border to end a pregnancy, the potential for criminal penalties when they return is very real in a post-Roe landscape. Up until now, states have primarily targeted abortion providers and clinics, as people seeking abortions were exercising their constitutionally protected right to end a pregnancy. But if new laws are upheld that extend greater legal protection to fetuses, the pressure on pregnant people around violating those new fetal rights will also increase. As more people opt for self-managing their abortions at home outside the formal health care system, experts say laws aimed at criminalizing these sorts of abortions are more likely.

With poorly regulated data privacy laws, aggressive prosecutors could amass a lot of evidence if they suspect a person obtained an illegal abortion, or an abortion that would not be legal in their home state. Missouri lawmakers introduced a bill last year that would have claimed legal jurisdiction for any pregnancy that was conceived within Missouri borders or in which the parents were Missouri residents at conception. It never received a vote, but lawmakers took another swing this year, introducing a bill that would target anyone in or outside of Missouri’s borders who “aids or abets” a Missouri resident’s abortion. Liberal states, in turn, are now trying to pass new protections for providers and allies who help end pregnancies for out-of-state residents.

“There are a whole host of unanswered questions that will now dominate,” Rebouché said. “Particularly as states start to enact their own abortion bans and do so on various timelines, I think what to expect in the immediate future is confusion.”

There is little legal precedent for these questions

Only two cases since Roe have really addressed questions about out-of-state legal liability, and it’s not clear how they would apply in a post-Roe America.

In its 1975 Bigelow v. Virginia decision, the US Supreme Court affirmed that a Virginia newspaper could print an ad for an abortion clinic in New York, where the procedure was legal, even though in 1971, when the ad originally ran, it was illegal in Virginia. The Court upheld the advertising on First Amendment grounds, and also noted that Virginia could not prevent its residents from traveling to New York for an abortion or prosecute them for doing so.

“A State does not acquire power or supervision over the internal affairs of another State merely because the welfare and health of its own citizens may be affected when they travel to that State,” the justices then wrote.

Then in 2007, the Missouri Supreme Court issued a decision in another abortion-related case, this one pertaining to a state law that prohibited individuals from “aid[ing], or assist[ing]” a minor’s abortion without parental consent. Planned Parenthood challenged the statute on First Amendment grounds, since the organization provided information to minors about out-of-state options, and alleged the law violated the commerce clause of the Constitution, since it would “requir[e] non-Missouri health care providers and others” to comply with the parental consent law. The court, citing Bigelow, dismissed the commerce clause claim, and said it was beyond the state’s authority. “Missouri simply does not have the authority to make lawful out-of-state conduct actionable here, for its laws do not have extraterritorial effect,” the court wrote.

Still, Donley, Cohen, and Rebouché caution from reading too much into these examples. “Though these two precedents contain strong statements against the application of extraterritorial abortion law, there is no reason to count on them being the final say on the matter,” they write in their preprint paper on post-Roe possibilities. “The first is dated and concentrated on the First Amendment, and the second is applicable in Missouri only.” The scholars note the Supreme Court could easily revisit Bigelow’s anti-extraterritoriality principle, and that it will indeed be “ripe for reassessment” once interjurisdictional abortion prosecutions begin.

But until these questions wind their way back up to the Supreme Court, aggressive prosecutors can and likely will experiment with testing the limits of the law.

For example, the law professors note, Georgia passed a law in 2019 which declared “unborn children are a class of living, distinct person” who deserve “full legal protection.” This law effectively banned abortions after just six weeks, as soon as fetal cardiac activity could be detected. It was later struck down by a district judge as a violation of Roe, but has since been stayed at the 11th Circuit Court of Appeals, pending a decision in Dobbs. The appellate court is now expected to lift that stay in the coming days or weeks, and Georgia’s Republican Attorney General Chris Carr already sent a letter on Friday urging the 11th Circuit to reverse the district court’s decision.

If the law goes into effect, an emboldened prosecutor could seek criminal penalties for a Georgian who crossed state lines to obtain a legal abortion, or even against anyone who helped them travel across state lines, under the rationale that their unborn child deserves full legal protection. States may struggle to enforce extraterritorial prosecutions, though, just as they’ve struggled to crack down on Aid Access, which dispenses medication abortion to US residents from overseas.

There is no legal consensus yet on these questions, and politics will likely play a role in shaping what plays out. While there are not many activists urging prosecutors to go after teenagers who import marijuana from other states, pressure to enforce state abortion bans to the fullest extent possible is a safer bet. Already, Texas Republicans are discussing new legislation that would allow district attorneys to criminally punish anyone who helps a person end a pregnancy outside Texas. And if an anti-abortion activist in a red state sees an opportunity to shut down or cause headaches for an abortion provider working in a blue state, it’s fair to expect they will try.

Some scholars, including University of Pennsylvania law professor Seth Kreimer and Yale law professor Lea Brilmayer, have argued that extraterritorial prosecution of abortion would likely be illegal under the Constitution. Others, like Chicago-Kent School Law professor Mark Rosen and University of Michigan law professor Donald Regan, have argued that states would likely be able to regulate out-of-state abortion activity of their residents.

Donley, Cohen, and Rebouché identify with a third category of scholars, including Harvard law professor Richard Fallon and Washington University in Saint Louis law professor Susan Appleton, who think it will be murky, variable, and highly contested for years to come.

Blue states are trying to shield providers from red-state prosecutions

With Roe in place, a provider in New York or California had little to fear from a prosecutor in Texas or Louisiana. Abortion was a constitutionally protected right for all citizens. But with Roe overturned, that legal calculus changes, and providers may find themselves vulnerable to states that have fully banned the procedure, or that want to punish anyone who helps their citizens get it.

To try to protect providers who offer abortion services to patients who might visit them from a state where it’s illegal, Democrat-controlled states have started to craft and pass so-called shield laws. These laws offer additional protections, like barring state agencies from helping another state’s criminal investigation, and ensuring that an abortion provider could not lose their professional license or face malpractice insurance penalties as a result of an out-of-state complaint.

While these shield laws are unlikely to face constitutional challenge, it’s unclear if they will really be effective, and Donley, Cohen, and Rebouché note they may also create new legal battles between red and blue states. “After all, if Illinois refuses to extradite an abortion provider to Georgia, will Georgia retaliate and refuse to extradite a gun dealer to Illinois?” they asked in their February paper.

Medication abortion also creates particularly complex legal challenges for states. Laws around telemedicine generally defer to the location of the patient, but could a provider in New Jersey, where abortion is legal, face penalty for mailing pills to a patient who lives in a state where abortion is illegal, if the patient traveled to New Jersey for the actual appointment? Or what if the pills were sent to an address in a Democrat-controlled state, and then forwarded through the mail to a state where it’s illegal, either by a mail forwarding service or by a friend?

“There will be efforts to crack down on PO boxes, but the person who just gives [a telehealth provider] their friend’s address and the friend then personally forwards the mail — that will be impossible to police,” Donley told Vox.

Heightened conflict between the federal government and Republican states has already started

In addition to new battles between red and blue states, legal scholars predict new and unprecedented tensions between states and the federal government in a post-Roe environment.

A preview of those fights came on Friday, when President Joe Biden gave a speech calling out “extremist governors and state legislators” who want to try to limit access to FDA-approved medication like mifepristone. Biden announced he was directing the federal Department of Health and Human Services “to ensure that these critical medications are available to the fullest extent possible and that politicians cannot interfere in the decisions that should be made between a woman and her doctor.” The same day, Attorney General Merrick Garland announced he would use the powers of the Justice Department to crack down on states trying to ban medication abortion.

A majority of states have imposed some sort of restriction on medication abortion, though many are looking to enact even more aggressive regulation going forward. It’s not clear yet whether states can outright ban drugs that have been approved by the FDA, since that agency has the sole authority to approve drugs in the US. “It’s an open question,” Patti Zettler, an associate professor of law at Ohio State University and former associate chief counsel for the FDA, told the Washington Post last month.

There’s some legal precedent for courts striking down state restrictions that conflict with FDA approval. In 2014 a federal judge struck down a Massachusetts effort to ban the opioid Zohydro, since the FDA had approved the painkiller.

Still, it might be harder for a court to strike down laws that in practice restrict access to the drugs, like Texas’s ban on obtaining pills after just seven weeks of pregnancy, but that do not technically ban its use.

For now, no one really knows, but the evidence suggests we’re entering a new legal era, not simply reverting to the pre-1973 status quo. As Breyer, Sotomayor, and Kagan write in their dissent, the Dobbs decision “puts the Court at the center of the coming ‘interjurisdictional abortion wars.’”