Tag Archives: Roe V Wade

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.”

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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.’”

Should you keep abortion pills at home, just in case?

Originally published in Vox on June 22, 2022
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Medication abortion, or taking a combination of the drugs mifepristone and misoprostol, is an increasingly common method for ending pregnancies in the United States. Reasons vary and overlap: Some women lack access to in-person abortion clinics; others prefer to end pregnancies in the comfort of their own home. Others seek out the pills because they cost far less than surgical abortion.

With more in-person clinics shuttering and a Supreme Court that’s threatening to overturn Roe v. Wade, a small but growing number of reproductive experts have been encouraging discussion of an idea called “advance provision” — or, more colloquially, stocking up on abortion pills in case one needs them later.

It’s an idea that has merit: Mifepristone has a shelf life of about five years, misoprostol about two, and both drugs work better the earlier in a pregnancy you take them. In states that are ramping up abortion restrictions, there’s often a race against the clock to access care. In Texas, for example, if you don’t realize until eight weeks in that you’re pregnant — which could be only a couple of weeks after a missed period — you would have already passed the state’s new legal deadline for obtaining abortion pills. But if you had already stored them in your home, or your friend or neighbor had, then you’d be able to take them.

In a 2018 nationally representative survey of women ages 18 to 49, 44 percent expressed support for advance provision, and 22 percent said they were personally interested in it. Those who had previously had a medication abortion and those who reported facing greater barriers to reproductive health care were more likely to support the idea.

Data on these kinds of abortions — often called “self-managed” or “self-administered” — are harder to track. Research published in 2020 estimated that 7 percent of women will self-manage an abortion in their lifetime, though this was calculated with the assumption that Roe was still in place. New Guttmacher data published last week on US abortion incidence found there were 8 percent more abortions in 2020 than in 2017, but self-managed abortions are excluded from this count.

“We know there are thousands of self-managed abortions that we aren’t capturing,” Rachel Jones, a Guttmacher research scientist, told Vox. “If the Supreme Court overturns Roe, and abortion becomes illegal in 26 states and people can’t travel to another state, then self-managed is going to be the only other option they have for an abortion.”

Talking more frankly about self-managed abortion goes against longstanding American cultural norms. For years US reproductive rights groups stressed that the decision to end a pregnancy “was made between a woman and her doctor.” Internationally, where abortion has been more heavily criminalized, there is less pressure to involve medical professionals. It was in the legally restrictive context of Brazil in the late 1980s that women first pioneered the use of misoprostol to self-manage their abortions.

Rebecca Gomperts, the Dutch physician who in 2018 founded Aid Access to deliver abortion pills to US patients, has been one of the most vocal advocates for advance provision, and began offering it as an option to people in all 50 states last fall. Costs for the pills range from $110 to $150, with a sliding scale for those who lack funds. Recently, in Politico, Gomperts encouraged doctors to begin prescribing mifepristone and misoprostol to those who are not pregnant, so they have the medication available if they need it later.

“Abortion pills are something that, actually, you cannot die from,” she said. “There’s no way that you can overdose on it. And what we know from research is that you don’t need to do an ultrasound for a medical abortion.”

The idea of getting medication in advance of need is nothing new. Doctors also used to commonly prescribe emergency contraception to women before it became available over the counter.

Right now large mainstream abortion rights groups are mostly staying quiet on advance provision, leaving lesser-known organizations like Aid Access and Plan C to try to get out the word. (NARAL and Guttmacher declined to comment, and Planned Parenthood did not return requests for comment.)

Aid Access and Forward Midwifery are among the few groups currently offering US patients the option to order pills in advance, though Elisa Wells, co-director of Plan C, said she knows others are considering it. “I was just having a conversation with a provider in Montana,” she told me. “We believe it will become more common. Sometimes we call it the ‘just in case’ plan, because unplanned pregnancy is so common.”

It’s a safe option for most patients

When it comes to safely ending pregnancies, medication abortion is over 95 percent successful, according to Guttmacher. Less than 0.4 percent of patients require hospitalization. The National Academies of Sciences, Engineering, and Medicine has also affirmed medication abortion as a safe method to terminate pregnancy, one with very low risk of complications.

Research published earlier this year in the medical journal Lancet found self-managed abortions specifically to be very effective, and with high rates of patient satisfaction.

Gomperts also urges more attention on misoprostol-only abortions, which are common internationally. The drug can be easier for women to access since misoprostol is less tightly regulated; it’s used for other ailments including stomach ulcers and managing miscarriages, and is sold over the counter in many countries.

While medication abortion is a safe option for almost everyone with an early pregnancy, the pills are not recommended for people who take blood thinners, who have bleeding disorders, or who are at high risk of ectopic pregnancies. (Ultrasounds are recommended for those in this latter category.)

Still, one upside of advance provision — and medication abortion generally — is the greater number of people who could potentially provide the pills, including primary care doctors. Another upside is that it could be easier to share pills with those who need the medication quickly but lack access to it. Research suggests the drugs are best taken within the first 10 to 12 weeks of a pregnancy.

Paying attention to legal risks and criminalization

Outside of groups that exploit international law like Aid Access, advance provision is unlikely to be a legal option in every state. Some states, for example, require patients to get ultrasounds before a provider can give them abortion pills. Other states are cracking down on abortion pills themselves.

While few states currently ban self-managed abortion outright, many have existing laws that overzealous prosecutors could use to go after women, like fetal homicide statutes. “I am concerned that if people stockpile, without knowing the legal risks or how to cover their digital footprints, they could be subject to criminalization,” said Renee Bracey Sherman, founder of the abortion storytelling group We Testify.

The National Right to Life Foundation also released model legislation in mid-June that encourages states to criminalize those who “aid or abet” illegal abortions, including those who provide instructions over the phone or internet about self-managed methods.

Even in states with fewer legal concerns, advance provision won’t be the right option for everyone. “It’s a potentially high cost for a patient that is unlikely to be covered by insurance,” said Daniel Grossman, a physician and a professor of obstetrics and gynecology at the University of California San Francisco. Not everyone can afford to spend $150 to have a backup method available, and some people will still need or prefer in-person clinic care.

It hasn’t gone mainstream, yet

In the days following the leaked draft of the Supreme Court’s decision to overturn Roe v. Wade, telehealth abortion providers reported spikes in internet searches and pill orders. Still, most Americans lack familiarity with not only abortion medication but also the few groups that currently provide the pills in advance. Some activists say leaders and more well-resourced organizations should do more to promote self-managed abortion as an option.

In December 2021, three UCSF reproductive health researchers, including Grossman, published an article calling advance provision “an unexplored care model that we believe holds promise and merits further study.”

Grossman told Vox that he believes more people should ask their primary care and reproductive health providers if they’d be open to prescribing or giving them abortion pills to store for later use. “Even if the doctor doesn’t want to, I think it’s worth just sparking a conversation with them and get their provider thinking,” he said. Grossman previously told Jezebel he’s found it challenging to get other researchers and health care providers to give advance provision the attention it deserves.

“We have ibuprofen in case of a headache, cough syrup in case of a cold, and Plan B in case of a broken condom,” said Bracey Sherman of We Testify. “It’s already normal for other health care and we should normalize it for abortion.”

Wells, from Plan C, said the historical restrictions placed on abortion have likely made some groups and individuals more reticent to talk about advance provision. “I think there’s probably a lot of fear about not wanting to break any rules,” she said.

Another factor limiting discussion, Wells suggested, is the way abortion has been heavily medicalized in the US, to the point where people believe the drugs have to be or are best administered by a medical professional. Attitudes are different internationally, she said.

“We have become so invested in saying that we need to have safe abortions and that doctors and clinicians and the clinics can provide that,” Wells said. “Clinicians have done a wonderful job, and we have to have all these different types of care options available, but [self-managed abortions] can be a bit of a threatening message to that whole system.”

Arkansas Legislature Introduces Texas-Style Abortion Ban

Originally published in Rewire News on December 8, 2021.
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As Arkansas launched a special legislative session Tuesday nominally dedicated to passing income tax cuts, a leading anti-choice Republican in the state senate introduced a copycat version of Texas SB 8, legislation that effectively bans abortions after six weeks and allows any citizen to sue those who help a pregnant person get the procedure.

Reproductive rights advocates have been bracing for this moment for several months, ever since Republican Sen. Jason Rapert, who has sponsored some of the most aggressive bills to restrict abortion access over the last few years, came out in September to praise SB 8.

“What Texas has done is absolutely awesome,” he proclaimed when it first went into effect. The U.S. Supreme Court heard arguments against SB 8 on November 1.

ROE HAS COLLAPSED AND TEXAS IS IN CHAOS.

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Earlier this year, Rapert pushed through an abortion ban that only permitted abortions to save the life of the pregnant person, but did not provide any exceptions for those impregnated by rape or incest. A federal judge in July preliminarily blocked the law, but it was just one of 20 abortion restrictions Arkansas passed this year alone.

In early October, Rapert, who did not return requests for comment for this story, announced that he would be filing a version of Texas SB 8 as soon as Arkansas’ special session launches, which at the time lawmakers thought would be on October 25.

“I am filing the Arkansas Heartbeat Protection Act with a civil cause of action—just like Texas,” he tweeted then. “I invite [Republican Gov. Asa Hutchinson] to put the bill on the call and legislators to co-sponsor.”

According to the state’s legislative rules, since Hutchinson did not include abortion on his “call,” Rapert had to rally two-thirds of his colleagues in order to have his bill considered in the special session. Rapert expressed confidence earlier in the fall that he could reach that support threshold. He also insisted that he must continue to be “creative” in his legislative pushes against abortion access, given that other bills he’s authored have been struck down in court. 

SB 13 was filed Tuesday afternoon with Rep. Mary Bentley as the bill’s other primary sponsor; 28 other Republicans co-sponsored it, clearing the two-thirds threshold.

Hutchinson had declined to say what he would do if the legislature passes copycat SB 8 legislation, but he said he thinks lawmakers should wait to see the decisions the Supreme Court hands down on SB 8 and Dobbs v. Jackson Women’s Health Organization, Mississippi’s 15-week abortion ban that the Court heard a week ago. Rapert has said he’s frustrated with Hutchinson’s stance.

Holly Dickson, the executive director of the ACLU of Arkansas, said trying to bring up a sensitive bill like this outside of the state’s regular legislative session is “unorthodox.” The ACLU has been monitoring the possibility of a Texas copycat law ever since Rapert issued his first threat.

“We’ll oppose any effort to do that and have been advising legislators against this blatantly unconstitutional move,” Dickson said.

Public opinion is somewhat mixed on the idea. In late September, a survey from Talk Business & Politics and Hendrix College, which polled 916 likely Arkansas voters on their opinions of Texas SB 8, found about 46.5 percent of voters would support a similar bill in Arkansas, and about 49.5 percent would oppose it. Only 4 percent of respondents said they didn’t have an opinion at the time. The pollsters found opposition was particularly strong among those under 30 years old, and among people of color.

In early November, the 23rd annual Arkansas Poll was released, which conducted 800 telephone interviews with randomly selected adults across the state, and found 41 percent of all very likely voters support laws that would make it harder to get an abortion. More than a quarter of very likely voters think abortion should be illegal under all circumstances, the highest percentage ever found in this poll, according to Charisse Dean of the Little Rock-based Family Council, a conservative research and advocacy group

Last month the national anti-abortion organization, Americans United for Life, ranked Arkansas as “the most pro-life state” in the country for the second year in a row. Arkansas already requires individuals seeking abortion to undergo a mandatory 72-hour waiting period, as well as to get two in-person visits at an abortion facility. Telemedicine for abortion is banned in Arkansas, and patients can access abortion only up to 20 weeks postfertilization, or 22 weeks’ gestation.

In mid-October, Planned Parenthood Great Plains Votes announced it would be launching an “aggressive statewide campaign” in Arkansas to defeat the proposed Texas copycat abortion ban. Among other things the organization said it had hired additional organizing and communications staff dedicated to the effort, would be hosting in-person and virtual events across the state to educate voters, and would be contacting over 20,000 state residents to discuss the implications.

“We’ve also really been targeting the legislature to help them understand the human impact,” said Emily Wales, the interim president and CEO of Planned Parenthood Great Plains.

Following the passage of SB 8 in Texas, visits by abortion-seekers into Arkansas jumped significantly. In September, Texas patients comprised 19 percent of Little Rock Family Planning Services’ caseload, after being less than 2 percent in August.

Many people are also traveling from Texas to Oklahoma for abortion care, though Oklahoma has passed its own wave of new abortion restrictions. In September, Planned Parenthood filed a lawsuit to block five of these new restrictions, which were set to take effect in November. The litigation has been successful; all five of the Oklahoma laws have been temporarily blocked so far.

More public-facing organizing against a Texas copycat law, Wales said, was delayed in Arkansas because the special session was pushed back from October. Advocates had said in mid-November that they expect in-person events against a copycat ban to pick up if and when Rapert’s bill is formally introduced.

“We will have in-person rallies outside the capitol,” Wales said. “If Texas has taught us anything it’s that you have to be really visible about what the outcomes are. We’re seeing patients in Texas who are shocked that their legislature passed [SB 8] and they weren’t paying attention before.”

In late September, a Republican state representative in Florida introduced the first copycat Texas bill, which almost identically mirrors SB 8. But reproductive rights advocates in Florida say they are less concerned that the bill will become law anytime soon, given the repeated failure of Florida lawmakers to pass a six-week abortion ban.

Karen Musick, the co-founder and vice president of the Arkansas Abortion Support Network, an all-volunteer nonprofit that helps Arkansans access abortion care, said they’ve definitely seen an uptick in donations since Texas SB 8 was passed but that their attention has largely been focused on organizing volunteers.

“People have really come out of the woodwork and said, ‘My home is available if someone needs a place to stay, if someone needs help getting to another place I will take them,’” Musick said. “We’re collecting all these people who have benefited from abortion care in the past and want to do as much as they can now to ensure the next generation has access too.”

Musick said that while there’s less they can do to stop the current legislature from passing new restrictions, they can at least focus on organizing people.

“Our job is to forge as many contacts as we can,” Musick said. “We need to build a base of transportation volunteers, escort volunteers, money and counseling volunteers.”

Strategies for a Post-Roe America — and for Post-Roe American Women

Originally published in The American Prospect on March 11, 2019.
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Independent journalist Robin Marty, one of the nation’s top reporters covering reproductive rights, has published a new book—Handbook for a Post-Roe America—with practical advice for women who might actually need to terminate a pregnancy in the future and for people who support abortion rights. While reproductive choice is at risk regardless of what happens at the Supreme Court, there’s little question in Marty’s mind that the landscape will soon look different in a world where Roe is overturned. The faster people accept that, she argues, the faster people can start preparing. This conversation has been edited and condensed.

Rachel Cohen: So, to get started, do you think we are headed for a post-Roe America?

Robin Marty: I am so certain at this point that I will even tell you it will be overturned in 2021. Abortion opponents already have all the cases they need, I’m fairly certain at this point it will be a case on banning D&E [dilation and extraction, a surgical abortion procedure typically performed during the third trimester or the later part of the second trimester] and that will be the case they use to overturn Roe. We know the Fifth Circuit is looking at it right now, and we’re pretty sure that court is going to say it’s not unconstitutional for Texas to do a D&E ban. And that would leave a split circuit decision, which would let the Supreme Court weigh in.

The Supreme Court will pick a case where lawyers can be extraordinarily gruesome. Abortion opponents love D&E bans because they’re so grotesque and no one can defend them without saying you have to pull out a limb.

I expect 2021 because they won’t have a case before the next presidential election, they know that’s the only way they can get the same evangelical voters out to get Trump re-elected. Once the election is over, they will go ahead and move as quickly as possible.

You’ve notably said you think the end of Roe would be a good thing.

I’m quite excited. Roe being overturned is the best thing that could happen to our movement. We’ve been treading water since 2010, we’ve seen all these red states that have been chipping away at access, but it took until Trump was elected and Roe was in honest-to-God jeopardy for all the really privileged and white people to understand that abortion could be cut off for everyone, not just the people who have already lost access. Ending Roe will put everyone on the same level.

Does that mean you supported Gorsuch’s and Kavanaugh’s confirmations?

Oh God, no! They are such a disaster for civil rights and more, even beyond just abortion.

Don’t you think privileged women in states like Massachusetts, New York, and California will continue to feel like the rollback in access doesn’t mean much for them personally?

But they will still be able to see the impacts more directly. Just being able to see people put in jail for accessing their own care—I mean people will get abortion pills, people will get caught, and there will be stark consequences—I think that will be the turning point. It’s like [in 2012] in Ireland when Savita [Halappanavar] died from a septic miscarriage after having been denied an abortion. That was a turning point for the country.

When we go post-Roe, what we’re going to have to decide as a movement, and as activists in general, is what is our new standard? What is accessible? Why does it have to be at a clinic? Why does it have to cost $500 out of pocket at a minimum? We’ve been so busy trying to protect this right that honestly isn’t that great. Is it worth protecting anymore? I don’t know that it is.

Would you say this is a mainstream view among pro-choice leaders?

It’s not a mainstream view, per se, but it’s something that I’ve been talking to audiences about as I’ve done my book tour. Everyone’s first thought is: How could you say Roe coming to an end is a good thing?! And then we talk about it, how now everyone will be in the same position as these marginalized communities that have one clinic in their state and a 72-hour waiting period, and once people understand that abortion is already inaccessible, and maybe it’s time to just get rid of Roe and start fighting for the human right to decide, people get it.

National organizations don’t like any of this, it would be dismantling the power of national organizations and effectively redistributing those resources to local groups. A lot of my work is about why we need to take abortion outside of clinics.

You mean to do more abortions at home?

Yes. In some way, what we’re seeing is the same debate we saw around home births and midwives. This isn’t very different from that, but there’s a resistance to the idea that we don’t need to do this procedure at a clinic, that we don’t have to have formal medical intervention. A lot of this can be left up to us. If we’ve already proven it’s not dangerous—which we have at this point, over and over—then we should be more forceful in pushing for that.

Your book was very practical and concrete. Can you talk about some of the specific suggestions you laid out for emergency contraception?

Emergency contraception was actually how the book started. As soon as [Justice Anthony] Kennedy announced his retirement, I saw a ton of people saying online they were going to give money to Planned Parenthood and stock up on emergency contraception. And my first thought was, “Whoa, now.” That led to a Huffington Post piece where I tried to say how you can do things like that in a more responsible way, which turned into this book.

Sterilization came up in your book as one way women could prepare for a post-Roe America. I was a bit surprised to see that. In your research, are you finding that’s already happening?

Yes, I am finding that women who have already decided they would not be interested in having children, or more children, are looking at this. The problem is it’s quite difficult to get sterilized—doctors don’t like to do it. It’s kind of a paternalistic thing, like saying you surely haven’t met the right man, or you’ll regret not being a mother. There are also a lot of rules—like you have to give consent for the procedure two weeks before you get it done. I have kids and I’ve also been sterilized.

In a chapter focused on organizing, you urged readers to focus on city councilmembers. I feel like the conversations around abortion restrictions has been focused heavily on state legislators and the U.S. Supreme Court.

The reason this book exists is to help take our attention off the bigger picture—which we’ve been paying attention to for a really long time. But national solutions are just not the best place for us to use our resources right now. My book is about drilling down as local as you can get, investing in your state, in your city, and in your local clinics.

One thing we’ve noticed about how power works is the more directly you’re involved in the area in which you can have real power, the more exponentially powerful that is. So for city councils, we’ve seen they are often the last bastion of protecting or ending access to abortion. We saw that when Whole Woman’s Health was trying to open a medication abortion clinic in Indiana. At first it was the city council that tried to block it, then the mayor overrode it, and then the city council tried to block it again. It’s now still going through lawsuits.

City councilmembers have say over things like zoning and noise ordinances, ensuring that buffer zones can be upheld. If there is a city council that is friendly toward abortion rights, that often impacts how the police will deal with people who protest and attend clinics.

Can you talk about the Pregnant Women’s Dignity Act?

The one thing we really need to do is get abortion out of the criminal code. One way to do that is through this law, the Pregnant Women’s Dignity Act, which is promoted by the Public Leadership Institute. It says if a person has any kind of poor birth outcome—it’s not her fault, it’s not something that should be investigated, this is not something that has a place of blame. It doesn’t matter if she did it on purpose, if it was by accident—it’s just a personal medical thing that has occurred and it does not involve the police or the courts.

You explore the idea of creating a new kind of infrastructure of housing, transportation, safety, and financial support for women who need to travel to get abortions in a post-Roe America.

I’ve been thinking about this a lot. Say that Roe is overturned and in Kentucky the state makes abortion completely illegal, and there’s just one remaining clinic. What happens to that clinic? Would that be a good place that you can then set up a hostel for women who need to then travel out of state to get an abortion? If Roe is overturned there will be no abortion in the entire Gulf area, no abortion in most of the Rust Belt. We’re talking about humongous chunks of the country. People are talking about how to make states like New York and Colorado these safe havens where people can go, but what’s the best way we can get people together so they can actually do it efficiently?

Can we bring all the people in the state of Kentucky together so they can all take a bus to Chicago together? Then none of them will have to worry about needing to drive. We have to think about how to work with systems that will be left, and how best to use it especially for those who aren’t going to have the funds to do long-distance travel.

Do you think we’ll increase the number of clinics in the future?

I’ve heard some people say, “Okay, we should build abortion clinics next to airports, so people can get off, get the procedure, and go right back home,” and my first thought was: Have these people tried to open a clinic lately?!

Just last [month] there was a piece in The Austin Chronicle about Whole Woman’s Health losing their Austin office, and they had spent months trying to find a new place they could move into. And this is in liberal Austin! There’s just so much pressure, no one wants to sell or lease their property to an abortion clinic.

I think for the most part what we have for clinics is as much as we’re going to get. And I don’t think that matters—I don’t think we should need as many abortion clinics. If people could just do it at home, as they should be able to especially with telemedicine, then we just need to have enough clinics that people can do follow-ups for later abortion or for people who can’t do it.

But haven’t studies shown that women prefer surgical abortion if they have the choice?

I totally understand why people would choose surgical abortion—you don’t have to worry about the follow-up, you don’t have to see the procedure, but if you look at Iowa, they had an extraordinarily successful telemedicine abortion program until [legislators] took it down. And what they discovered in Iowa was it didn’t increase the number of people having abortions, they just were able to have them earlier.

Your book also looks at the question of civil disobedience and direct action in a post-Roe America.

Yes, I think we’re going to see a lot more civil disobedience. There was a Mother Jones article recently about a woman who sold medication abortion online for years, and that finally got shut down by federal agents. The only thing that made the police finally get involved was because a man used the medication he bought from her to commit a crime.

As I was reading it I thought, how many people would need to start online websites, offering medication abortion for sale, before the FDA threw up their hands and said I can’t keep up with them all? That’s the kind of thing I’m thinking about. What’s the critical mass where so many people are breaking the law that it’s no longer feasible for authorities to keep up? And who are the right people to do it and how do we organize en masse?

What are some other examples of civil disobedience that you can imagine?

There’s a bill that was just reintroduced in Congress, and it comes up every year, the Child Interstate Abortion Notification Act, or CIANA, which would make it a crime to transport a minor across state lines to get an abortion without parental consent. One of the best things NARAL ever did was they dubbed this the “Jail Grandma law.” They brought to mind a picture of a young girl who goes to a different state to get an abortion, and for some reason her parents couldn’t take her so her grandma takes her across the border. Are we really going to throw grandma in jail? That ground everything to a halt, and that is a perfect example of why we need old white ladies to do civil disobedience.

So the last thing I wanted to ask you about was surveillance, and why being conscious of that will be important in a post-Roe America.

One of the reasons it’s really important to pay attention to what you’re saying over open phone lines, over what you’re searching on Google, over text messages, is that when Purvi Patel was arrested in Indiana for allegedly inducing her own abortion, the state went back and forth on is this murder? Is this feticide? A lot of what they used against Patel were texts in her own phone. We need to be aware that if we do decide that it’s time to organize outside the legal bounds, or if someone is going to try to do an abortion outside of a legal clinical setting, that person will need to be really careful about what they put down in writing.

I’m someone who generally hated being pregnant, I did not have comfortable pregnancies. I don’t know how many times I texted someone saying, “God, I wish I wasn’t pregnant.” If I had had a miscarriage, what would stop some suspicious doctor or some overzealous prosecutor to say, hm, she had a miscarriage, I wonder if she induced her own abortion, and then found that text?

 

A Legal War in Arkansas Threatens Abortion Rights Everywhere

Originally published in VICE on September 7, 2017.
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When Donald Trump ran for president, despite his long history of pro-choice positions, he essentially offered evangelical Christians a deal: Help elect me, and I will appoint pro-life, conservative justices to the Supreme Court. Sure enough, less than three months into his presidency, Trump’s first SCOTUS appointee—Neil Gorsuch—was confirmed, and anti-choice advocates seemed to be one step closer to their ultimate goal of overturning Roe v. Wade.

It may take another appointee to truly tilt the scales of justice against reproductive rights in America’s highest court. But in the meantime, conservatives have been eyeing the Eighth Circuit Court of Appeals, based in St. Louis, Missouri, as a vehicle to bring such a challenge. That’s where, in 2015, appellate judges urged the nation’s highest court to revisit existing abortion jurisprudence, and turn matters over to the states, as conservatives have long dreamed.

Now that same federal appeals court, which may be more hostile than any other to abortion rights, is getting a bunch of new opportunities to go after a woman’s right to choose in Arkansas—and maybe even set the stage for the end of Roenationally.

Over the past several years, legislators in Arkansas—one of seven states under the Eighth Circuit’s purview—have passed some of America’s most restrictive abortion laws. Already in 2017, Arkansas passed a statute that would criminalize doctors who perform dilation and evacuation (the most common second-trimester procedure), and also permit husbands to sue to doctors to prevent their wives from obtaining abortions—with no exceptions even for rape or incest.

Set to go into effect on July 30, the law was blocked after the American Civil Liberties Union, the ACLU of Arkansas, and the Center for Reproductive Rights sued over it and three other recently-passed abortion restrictions. Lawyers brought the suit on behalf of a physician working at one of the last two abortion clinics in the state, and argued the laws posed unconstitutional burdens on a woman’s right to choose.

On July 28, federal judge Kristine Baker blocked the laws’ enforcement, and Arkansas Attorney General Leslie Rutledge filed for an appeal two weeks ago. A spokesman for the AG did not return multiple requests for comment.

What should worry abortion-rights advocates is that there’s plenty of reason to suspect the Eighth Circuit will be sympathetic to Rutledge’s challenge. In March 2016, Judge Baker issued another injunction against a 2015 Arkansas lawrequiring physicians who prescribe abortion-inducing drugs to secure contracts with doctors with hospital admitting privileges—a high bar to meet in the increasingly conservative state, and one the American College of Obstetricians and Gynecologists and the American Medical Association said had no medical basis. This past July, the Eighth Circuit lifted Baker’s injunction, ruling she would need to more concretely prove that a sizable number of women will face harm under that law.

In an interview with VICE, Steve Aden, chief legal officer and general counsel for Americans United for Life, said he felt the Eighth Circuit’s request for “some real math” was reasonable. He also defended the admitting privileges requirement as a common-sense measure to protect women’s health, noting that other outpatient surgical procedures generally require it. “If you or I go to a clinic and get Lasik or a colonoscopy, chances are really good that the doctors will have admitting privileges,” he said.

Meanwhile, the US Supreme Court last year heard arguments for Whole Woman’s Health v. Hellerstedt, widely considered to be the most significant reproductive rights case in nearly 25 years. In a 5-3 decision, the justices ruled that a package of Texas abortion restrictions imposed an unconstitutional burden on women seeking to end their pregnancies.

Fatima Goss Graves, the president and CEO of the National Women’s Law Center, told VICE anti-abortion opponents haven’t been much deterred by that outcome. On the contrary, she said, they are eagerly working to put more abortion cases before the Supreme Court as soon as possible. “They are still purposely trying to pass extreme laws that conflict with Whole Women’s Health, with Roe, so they’ll [then] be challenged in court,” she said. “That is the strategy.”

Another Arkansas case that could reach the Supreme Court concerns conservative boogeyman Planned Parenthood. In 2015, following the release of doctored videos purporting to show Planned Parenthood illegally profiting from the sale of fetal tissue, Arkansas Republican Governor Asa Hutchinson announced he would be terminating Medicaid contracts with the women’s health organization. Judge Baker blocked the move that September, but last month, a three-person panel on the Eighth Circuit decided Arkansas could cancel its Medicaid contract with Planned Parenthood—a notable departure from rulings in the Fifth, Seventh and Ninth Circuits. On August 30, the plaintiffs appealed to make their case again before the entire Eighth Circuit.

Aden, of Americans United for Life, thinks this case stands a shot of reaching the Supreme Court given the Eighth Circuit’s first decision diverged so sharply from other Appeals Courts nationwide.

I asked Bonyen Lee-Gilmore, a spokesperson for Planned Parenthood Great Plains (an affiliate overseeing Arkansas, Kansas, Missouri, and Oklahoma), if they would appeal to the Supreme Court, should the full Eighth Circuit uphold the Medicaid ruling. “When it comes to next steps in the legal world, we really play it one step at a time,” she said. “Every time a decision comes down, we’re evaluating all our legal options, and the reality is we could end up in the Supreme Court, but we’re not there yet. Right now we’re just seeing if we can successfully secure an en banc appeal.” (To hear a case ‘en banc’ means before the entire bench of judges, rather than a three-person panel.)

It’s worth noting that even though Arkansas’s governor cancelled state Medicaid contracts with Planned Parenthood over the 2015 fetal tissue videos, three Republican-led congressional investigations and 13 state-level probes—including one by a Texas grand jury—found no evidence of wrongdoing.

Gillian Metzger, the Stanley H. Fuld Professor of Law and vice-dean at Columbia Law School, thinks the Eighth Circuit “has really pushed the envelope” on constitutional retraction of reproductive rights in America. But whether these specific cases make it to the Supreme Court, she said, comes down—as always—to how willing justices are to engage with the abortion issue again. “The bigger question is does the Court have an appetite for this after 2016? And my guess it might wait a little bit to see how the Whole Women’s Health decision plays out,” she said.

In the meantime, President Trump will have the opportunity to fill three vacancies on the Eighth Circuit. If all are confirmed, according to longtime legal writer Rox Laird, only one of the Eighth Circuit’s eleven judges will have been appointed by a Democratic president, making it “the most ideologically lopsided of all the US Court of Appeals.”

Even if pro-choice advocates secure Medicaid funding for Planned Parenthood and defeat this round of abortion restrictions in the Eighth Circuit—by no means a safe bet —advocates aren’t expecting legislators to slow down their anti-abortion efforts any time soon. In mid-August, Planned Parenthood Great Plains and the ACLU argued yet another case in Arkansas federal court, protesting a law mandating the suspension of an abortion provider’s license for any minor error found during an inspection. That rule doesn’t apply to any other licensed health center in the state.

“We’ll be on high alert when the legislature returns in 2019 and continue to fight these extreme attacks on women and their rights,” said Rita Sklar, the executive director of the ACLU of Arkansas. “Often, the only way to get Arkansas politicians out of the exam room is to take them to court.”