In a shopping area in the New York neighborhood of Queens, in front of a hair salon and next to a McDonald's, two security guards indicate the entrance to the Jamaica sexual health clinic. For decades, it has been the neighborhood's go-to location for sexually transmitted disease testing and HIV treatment. Joaquín Aracena, from the Office of Public Health Clinics, proudly shows off the latest expansion: the reproductive health wing. With freshly painted white walls and pastel green doors, it has a much less institutional look than the rest of the clinic.
“I was able to get this space after Roe v. Wade was overturned,” he explains. The clinic now offers free, walk-in medical abortions. There is no doubt that the word is spreading; Last year she performed just over 700 abortions, in January there were 100 and this morning the two nurses have already given four women an opaque bag with the pills necessary to terminate the pregnancy (in addition to a care package with heating pads, painkillers and a information brochure). The clinic has received visitors from out of state, but most of the patients are local.
That pregnancy termination service is one of the most unexpected results of the Supreme Court's decision in 2022 to overturn the Roe ruling, a ruling that returned the issue of abortion to the states and triggered a series of bans. That court decision gave the municipal government new energy to take a much more active role in coordinating access to the procedure, recalls Ashwin Vasan, commissioner of the city's Health Department. “Our main goal was to make sure we expanded access to abortion services in New York and redoubled our efforts to make the city the safe haven it has always been,” he adds. That meant placing billboards in Arizona and Texas, launching a central information telephone line and opening new clinics in areas of the city not served until then. The Jamaica clinic's pregnancy termination service became operational less than nine months after the ruling in Dobbs v. Jackson, which overturned the Roe ruling.
Although much of the political debate in the United States has revolved around whether and how long abortion should be legal, legality alone is not enough to make it possible. There are many obstacles (practical, economic, social) that can get in the way of a woman; even in states that, on paper, allow abortion. One of the most positive consequences that can come from Dobbs is the improvement of access in states with favorable criteria for abortion.
According to new data from the Guttmacher Institute, a research group that supports abortion rights, more than one million abortions were performed in the United States in 2023, which represents a 10% increase compared to 2020 and the highest number in more than a decade. This is a surprising increase, since the procedure is now banned in 14 states and has been restricted in several more. The number of abortions has increased in almost all states without a ban. The steepest increases have taken place in states neighboring those that have banned it: in Illinois, abortions have increased 72% since 2020; in Virginia, 76%; and in New Mexico, an impressive 257%. However, neighboring states that do allow it have also recorded increases (see map).
Last year, more than 160,000 women (more than 400 a day) crossed state borders to terminate their pregnancies, compared to 67,000 in 2020 (despite being a year with covid). Taking into account that almost a third of women today live in states that prohibit abortion completely or after six weeks, such an increase in displacement was foreseeable. More surprising is that a significant portion of the overall growth in pregnancy terminations in the United States is the result of an increase among residents of states that allow the procedure. It is estimated that in 2023 there were 21,470 more resident abortions in California than in 2020 (which represents 88% of the state increase), in Illinois there were 12,350 more (32% of the increase) and in New York 20,460 (97%) . Overall, in states without a ban, more than half of the increase was due to local women having more abortions.
That growth is most likely due, at least to some extent, to efforts to improve access in those states. Some of the initiatives predated the Dobbs ruling, but they accelerated as anti-abortion politics intensified. In early 2023, 20 Democratic governors launched the Alliance for Reproductive Freedom; They pledged to “collaborate to strengthen abortion protections across the United States” and proclaimed: “This fight is not over.”
Because costs can be a major barrier, several states have reduced out-of-pocket costs for patients. Illinois, New Mexico and New York have increased Medicaid reimbursement rates for first- and second-trimester abortion procedures by more than 200%, according to a forthcoming analysis from KFF, a health research organization. That means there may now be more clinics willing to accept low-income patients. In ten states, health insurers are now required to cover pregnancy terminations, up from six before the Dobbs ruling. California is one of a handful of states that has gone even further. Require health insurers to eliminate all personal expenses.
What has contributed most to expanding access are abortion pills, which today account for 63% of pregnancy terminations in the United States, up from 45% in 2019 (see chart). Medical abortions are cheaper than surgical abortions, and easier for clinics and (often) patients to perform, especially in rural areas. They are effective in the first trimester, a period in which 93% of abortions occur. Its expansion can largely be attributed to the success of a telehealth experiment carried out during the pandemic and, above all, to the Food and Drug Administration (FDA) relaxing its distribution rules in January 2023. On March 26, the Supreme Court will consider whether to tighten the rules again for one of those drugs, mifepristone.
In 2020, only 7% of providers offered abortions through telemedicine; In 2022, the figure had increased to 31%. In October of last year, New York City's public health system became the first to facilitate abortions virtually. Commercial providers are coy about sharing pricing information, but Sylvia Ghazarian of WRRAP, an abortion fund, says she has been able to arrange a deal with providers where a patient gets a complete package for $150 for a abortion with virtual assistance (with two consultations, medication and shipping costs). Mai Flemming of Hey Jane, one of several virtual-only abortion providers, claims to offer pharmacological abortions at “a fraction” of the cost of traditional clinics. She has seen a very noticeable increase in clients ordering pills from states bordering more restrictive ones, such as Colorado, Illinois and New Mexico.
Caitlin Myers of Middlebury College estimates that, on a net basis, the country has lost about 49 in-person establishments since the Dobbs ruling. And while it is clear that some clinics are experiencing difficulties due to the additional influx, the estimated proportion of women with a waiting time longer than two weeks (almost one in five) remains almost unchanged.
Additionally, abortion facilities have strengthened legal protections for both patients (e.g., data privacy) and providers (e.g., professional liability insurance). In some of them, state constitutions have been amended to include the right to abortion; and several more are expected to make a consultation on the matter taking advantage of the general elections in November. Six states already have telemedicine “shield laws” that explicitly protect professionals from potential lawsuits if they prescribe and ship abortion pills to patients in states that prohibit abortion.
Alternative explanations for the rise in abortions across the country, beyond those efforts to reduce barriers, do not appear to hold up. For example, the increase does not appear to be the result of an uptick in unintended pregnancies, the rate of which (except for a brief dip during the Covid-19 pandemic) has not changed much since the Dobbs ruling. In any case, the New York Health Commissioner sees no reason to believe that this is happening in his area: “There is nothing to indicate that anything has changed in terms of the volume of unwanted pregnancies,” says Vasan; That is why he believes that the increase is probably the result of greater access, although this cannot yet be stated categorically.
Still, it would be a mistake to conclude that all is well in post-Roe America. Although abortion pills can be a welcome solution to unplanned early pregnancies, for women in states with bans who need to abort later (often due to fetal abnormalities that are only detected at the 20-week scan) , abortion in the United States is more difficult than ever. For these women, the fight continues.
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Translation: Juan Gabriel López Guix
