Midwest Abortion Providers Scramble to Prepare for a Post-Roe World

Not quite two years ago, Julie Amaon saw the future of many abortions in the United States in the shape of two small pills. She lived in Minnesota, where abortion clinics are clustered in cities, meaning that women in rural areas and small towns often travel long distances, struggle with child care, and miss work when they want to end a pregnancy. Amaon, a family doctor, started conducting telehealth appointments and arranging for pharmacies to send the pills—mifepristone, to block progesterone, and misoprostol, to cause contractions—by mail. In the pandemic winter of 2021, she took to the road, driving twelve hundred miles a week in a rented R.V., sometimes logging twelve-hour days to meet pregnant patients where they lived.

That year, Amaon treated thirteen hundred and thirty-five patients. In the first four months of 2022, she has already seen nine hundred and one. Her organization, Just the Pill—which was founded by a friend—now employs fifteen people and recently hired a second doctor. To address the need in neighboring states with highly restrictive abortion laws—such as North and South Dakota, where clinics are few, waiting periods are mandatory, and telemedicine appointments for abortion are prohibited—Just the Pill continues to grow. Now patients who live in the Dakotas can drive across state lines into Montana, Minnesota, or Wyoming, pull over to the side of the road, and connect with Amaon by phone or video. If all goes well, she authorizes a pharmacy to send the pills to a designated pickup site.

When Politico revealed, earlier this week, that the Supreme Court was poised to overturn Roe v. Wade, few in the reproductive-rights community were shocked. Organizations like Just the Pill have been preparing for months—and, in some cases, years—for a ruling that would end federal abortion protections, allowing states to do as they please with a woman’s right to choose. “The decision is going to be bad,” Amaon told me, before Justice Samuel Alito’s draft opinion leaked. “There’s going to be more patients than anyone knows what to do with.”

If Roe is indeed overturned, the stark political divide among states will create streams of medical migrants, travelling great distances and by any available means. Pregnant people blocked from getting an abortion in a place such as Arizona could drive to California to seek care. From Oklahoma, it could mean heading north to Kansas, where the right to an abortion is, for now, enshrined in the state constitution, or flying to Denver. For states that have sharply limited abortion, including Texas and Missouri, the outflow of patients is already intense. “When I started my career in abortion care in Missouri, a little over ten years ago, we saw probably six thousand abortions a year in our St. Louis clinic. This year, we might see a hundred,” Colleen McNicholas, the medical director for much of Planned Parenthood’s operations in Missouri and part of Illinois, told me. “We’ve already been living in this post-Roe world.”

The abortion landscape is shifting, in ways predictable and not. In Missouri, Eric Schmitt, the Republican attorney general, said this week that if Roe goes, he would immediately activate a ban passed by the legislature. Abortion would only be permitted in cases involving a medical emergency; performing an abortion for any other reason would be a felony punishable by prison. Yet Republican governors in Vermont, New Hampshire, and Massachusetts pledged to preserve abortion rights. And, in Wisconsin, where Republicans control the legislature but Democrats hold major statewide offices, Josh Kaul, the Democratic attorney general, said that he would not enforce a ban that has been on the books since 1849. (Local officials, though, could still enforce it. One Republican challenger in the upcoming primary election has said that Kaul’s refusal should disqualify him from office.)

A few weeks ago, I visited a new health center in Chicago’s downtown Loop, where Planned Parenthood has been rushing to accommodate a growing numbers of patients—some call them abortion refugees—from other states. Security cameras film everyone walking in and out of the waiting room, where one wall is painted a dramatic pink. Behind the front desk, a door leads to a long, brightly lit corridor lined with exam and counselling rooms. The facility is designed for patients seeking medication abortions or other reproductive-health care, from contraception and pelvic exams to S.T.I. treatment, clearing space in other clinics that perform surgical abortions. More than nine thousand six hundred people travelled to Illinois for an abortion in 2020, a seventy per cent increase from 2018. If Roe falls, Illinois health centers could see more than twenty thousand extra patients in the first year, Planned Parenthood estimates.

Attempts to make Illinois a safe harbor for abortion intensified four years ago. On June 27, 2018, the day Justice Anthony Kennedy announced his retirement, opening a seat for Brett Kavanaugh and the Court’s eventual anti-Roe majority, Planned Parenthood leaders were holding a national strategy session in Chicago. Within a year, the Illinois legislature declared abortion a “fundamental right.” Medicaid covers abortion for low-income patients, and a parental-notification requirement for minors will expire on June 1st. “Abortion will always be safe and legal here in Illinois,” J. B. Pritzker, the Democratic Governor, running for reëlection, said this week.

Across the state, providers have been expanding their operations to prepare for the influx of travelling patients. Planned Parenthood is training more staff, keeping clinics open on additional days, and expanding physical capacity. Its seventeen health centers include facilities situated, by design, close to the borders of Wisconsin, Missouri, and Indiana—three states where abortion access is already restricted. If Roe falls, all the surrounding states are expected to tighten abortion laws. Chicago is an easy destination for patients who can afford the flight, but many others drive. Illinois is also a magnet for patients from farther afield. The city of Cairo, at its southern tip, is three hours by car from Mississippi. Arkansas and Tennessee are even closer.

The Chicago Abortion Fund, which helps patients with money, logistics, and emotional support, assisted roughly a hundred and eighty people in 2018. This year, the organization is receiving an average of more than five hundred calls a month, eighty-five per cent from outside of Illinois. Most come from the Midwest, but patients are increasingly calling from Louisiana and Texas. (The fund has fielded calls from thirty-three separate states.) “It feels like each month is a record-breaking month,” Meghan Daniel, part of the team that coördinates support at the fund, said. Donations typically increase when abortion is in the news, but leaders of access funds across the country worry that the current uptick won’t be enough.

“This is catastrophic, not just for Missourians but for people throughout the South,” McNicholas, the St. Louis-based medical director, said, of the Court’s expected decision. “Egregious, disappointing, and, quite frankly, embarrassing. The human and financial cost of care is going to rise exponentially.” Most immediately, if Missouri’s trigger law takes effect, almost all abortions would be prohibited. “If I’m in the middle of an appointment with a patient, I have to stop,” McNicholas said. The clinics would remain open for other health care, including birth control, Bonyen Lee-Gilmore, Planned Parenthood’s vice-president of strategy and communications for the region, told me. But doctors, permitted to perform abortions only when the patients are at risk of death or “substantial and irreversible physical impairment,” would have a judgment call to make. “Any medical provider will tell you that medicine is never black-and-white,” Lee-Gilmore said. The law would force doctors to “question whether the care they’re about to provide could come with criminal punishments.”